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GYNECOLOGICAL 
AND  OBSTETRICAL 
TUBERCU  LOSIS 


GYNECOLOGICAL 
AND  OBSTETRICAL 
TUBERCULOSIS 


BY 


CHARLES  C.  NORRIS,  M.D. 

ASSOCIATE    IN    GYNECOLOGY,    UNIVERSITY    OF    PENNSYLVANIA    SCHOOL    OF    MEDICINE; 
ASSISTANT       PROFESSOR      IN      GYNECOLOGY- OBSTETRICS,      GRADUATE      SCHOOL      OF 
MEDICINE,    UNIVERSITY    OF    PENNSYLVANIA;    ASSISTANT    GYNECOLOGIST, 
HOSPITAL  OF  THE  UNIVERSITY  OF  PENNSYLVANIA;   GYNECOLOGIST 
TO  THE   CHILDREN'S   HOSPITAL,  PHILADELPHIA;    CONSULT- 
ING    GYNECOLOGIST     AND      OBSTETRICIAN,      HENRY 
PHIPPS      INSTITUTE      OF     THE      UNIVERSITY 
OF      PENNSYLVANIA 


GYNECOLOGICAL  AXD   OBSTETRICAL   MONOGRAPHS 


D.  APPLETON  AND  COMPANY 

NEW  YORK  LONDON 

1921 


COPYRIGHT,    19  21,    BY 

D.  APPLETON  AND   COMPANY 


PRINTED  IN  THE  UNITED  STATES  OF  AMERICA 


. 


PREFACE 

The  current  literature  contains  exhaustive  references  to  the  various 
forms  of  tuberculosis  which  are  of  especial  interest  to  the  gynecologist 
and  obstetrician.  However,  few  monographs  dealing  exclusively  with 
the  subject  have  been  written. 

Pulmonary  tuberculosis  is  one  of  the  most  frequent  diseases,  and 
when  present  in  the  pregnant  woman  has  a  definite  bearing  on  the 
ultimate  outcome  of  the  case. 

Tuberculosis  of  the  female  genital  tract  and  peritoneum  is  of  fre- 
quent occurrence  and  is  usually  secondary  to  tuberculosis  elsewhere  in 
the  body.  Not  only  do  these  cases  exhibit  characteristics  requiring 
special  local  treatment  but,  due  to  the  fact  that  other  foci  of  tubercu- 
losis are  generally  present  elsewhere,  often  in  the  lungs,  particular  care 
should  be  exercised  in  the  choice  of  an  anesthetic  and  during  con- 
valescence following  any  surgical  procedure.  Furthermore  many  surgical 
patients  who  are  suffering  from  some  non-tuberculous  pelvic  lesion  are  the 
incumbents  of  pulmonary  tuberculosis  and,  therefore,  require  special  safe- 
guards, both  during  and  following  operation.  As  has  been  stated,  refer- 
ences to  tuberculosis,  as  it  has  bearing  upon  gynecologic  and  obstetric 
practices,  are  rife  in  the  current  literature,  but  the  space  devoted  to  this 
subject  in  the  text  books  is  often  extremely  brief. 

For  these  reasons  an  attempt  has  been  made  to  present  the  entire 
subject  in  one  volume. 

No  effort  has  been  made  to  utilize  all  the  literature  bearing  on  the 
text  contents  in  the  present  monograph.  An  endeavor  has,  however, 
been  made  to  incorporate  references  to  the  more  important  articles 
bearing  upon  the  various  subjects. 

Some  of  the  material  employed  in  the  Chapter  on  Pulmonary  Tuber- 
culosis and  Pregnancy  has  been  previously  utilized  in  an  article  which 
appeared  in  the  American  Journal  of  Obstetrics.  A  part  of  the  material 
used  in  the  chapter  on  Congenital  and  Placental  Tuberculosis  has  previ- 
ously appeared  in  the  Transactions  of  the  American  Gynecological 
ociety.  In  both  instances  the  material  has  been  added  to  and  brought 
up  to  date. 

I  wish  to  acknowledge  my  indebtedness  to  the  following  authorities 


vi  PREFACE 

for  much  of  the  material  utilized  in  the  preparation  of  the  historic 
review :  Sir  William  Osier,  Waldenberg,  Predohl,  Johne,  and  especially 
to  Dr.  J.  Whitridge  Williams,  whose  valuable  monograph  on  Tubercu- 
losis of  the  Female  Generative  Organs  has  been  extensively  drawn  upon. 

Charles  C.  Norris 

PHILADELPHIA 


CONTENTS 


I.    Historical  Sketch I 

Early  recognition  of  tuberculosis,  i — Varieties  of  the  disease,  i — Atrophic, 
cachectic  and  ulcerative,  i — Practical  knowledge  of  certain  features  of 
tuberculosis  held  by  pre-Hippocratic  writers,  i — History  of  the  disease 
reviewed  by  Osier,  and  other  illustrious  members  of  the  medical  pro- 
fession, i — Connection  between  tuberculosis  nodes  and  phthisis  first 
indicated  by  Sylvius  (1695),  2 — Baillie  (1793)  first  to  recognize  tuber- 
culosis in  organs  other  than  lungs,  2 — Laennec,  originator  of  the 
stethoscope  recognized  unity  of  scrofulous  nodes  and  phthisis,  2 — 
Open  air  treatment  recommended  by  Samuel  Morton  (1834),  2 — First 
successful  inoculation  by  Klencke  (1843),  2 — Various  views  regarding 
etiology  of  this  condition,  2 — Valuable  work  of  Furnival  (1842)  and 
others,  2 — Tubercle  bacillus  discovered  by  Koch,  3 — Genital  tuberculosis 
first  recognized  by  Morgagni,  3 — Historical  review  of  genital  tubercu- 
losis, 4. 

II.    The  Diagnosis  of  Tuberculosis  of  the  Female  Genital  Tract  by  Lab- 
oratory   Methods 6 

Cervix  and  lower  genital  tract,  6 — Methods  of  treatment,  7 — Curettage,  7 
— Value  of  examination  of  leukorrheal  discharge  in  tuberculous 
endometritis,  7 — Organisms  likely  to  be  mistaken  for  the  tubercle 
bacillus,  8 — Smegma  bacilli,  8 — Study  of  morphology  and  of  staining 
by  ordinary  methods,  9 — Grethe  methods,  9— Czaplewski  method,  9 — 
Etiology  of  smegma  bacilli,  9 — Bacillus  leprae,  10 — Resemblance  to 
tubercle  bacillus,  10 — Differentiation,  11 — Cultural  methods  and  clinical 
study,  11 — Animal  inoculation  almost  positively  diagnostic,  11 — Danger 
of  mistaking  malignant  neoplasms  for  certain  forms  of  tuberculosis,  12 
— Diagnostic  use  of  tuberculin  in  gynecological  conditions,  12 — Sum- 
mary of  histologic  examination,  12. 

III.  Pathology 15 

Two  distinct  forms  of  genital  tuberculosis,  ulcerative  and  hypertrophic, 
16 — Histologic  examination  of  ulcerative  form,  16 — Hypertrophic 
variety  demonstrated  by  staining  or  inoculation,  17 — Tuberculosis  of 
the  vagina,  18 — Ulcerative  form  the  most  frequent  variety,  18 — 
Histologic  examination,  19 — Hypertrophic  form  in  relation  to  miliary 
tuberculosis,  19 — Tuberculosis  of  the  cervix,  ulcerative,  papillary, 
miliary,  and  interstitial,  20 — Histologic  examination,  22 — Character- 
istics and  differentiation,  23 — Corporeal  endometritis,  miliary  and 
caseous,  23 — Study  of  histologic  and  pathologic  characteristics,  25 — 
Myometritis  frequent  occurrence  in  advanced  cases  of  tuberculous 
endometritis,  26— -Infections  of  the  endometrium,  27 — Intramural  ab- 
scess, 27 — Tuberculous  deciduitis,  30 — Histologic  examination,  30 — 
Placental  tuberculosis,  31 — Macroscopic  appearance,  characteristics 
and  forms,  31 — Intravillous  tuberculosis,  33 — Intravascular  chorionic 
lesions  and  chorio-amniotic,  34 — Tuberculosis  of  fallopian  tubes,  34 — 
Tuberculosis  of  the  ovary,  41 — Peri-oophoritis  and  oophoritis,  41 — 
Histologic  examination,  42. 

IV.  Congenital  and  Placental  Tuberculosis 44 

Placental  transmission  of  tuberculosis,  44— Conflicting  reports  of  find- 
ings, 44 — Types,  acute,  chronic,  45 — Errors  in  technic,  45 — Definition 
of  congenital  tuberculosis,  45 — Discrimination  between  congenital  inf^c- 

vii 


viii  CONTENTS 

CHAPTER  PAGE 

tion  and  congenital  predisposition,  45 — Etiology,  46 — Germinative  in- 
fection: Spermatozoic,  46— Variety  of  infection,  47 — Experiments  of 
Waldstein  and  Ekler,  47 — Observations  of  medical  experts,  47 — Un- 
fertilized ovum,  49 — Ovarian  infection  and  germinal  transmission  of 
disease,  49 — Congenital  germinative  tuberculosis,  49 — Placental  and 
fetal  tuberculosis,  50 — Opinion  of  Baumgarten  and  others,  51 — Tubercle 
bacilli  in  the  blood  stream,  51 — Views  of  Delore  and  other  investi- 
gators, 51 — Infarcts  described  by  Williams,  53 — Criticism,  60 — Period 
at  which  intra-uterine  transmission  occurs,  61 — Predisposing  factors 
to  placental  or  congenital  tuberculosis,  62 — Undoubted  cases,  73 — 
Anatomical  changes  and  presence  of  tubercle  bacilli,  81 — Histologic 
changes  and  presence  of  tubercle  bacilli,  82 — Demonstration  of  bacilli 
by  staining  or  by  inoculation  of  animals,  83 — Conclusions,  85. 

V.     Routes  of  Infection  in  Genital  Tuberculosis 95 

Primary  genital  tuberculosis,  95 — Modes  of  infection,  96 — History  of 
cases,  97 — Relative  infrequency  in  women,  98 — Analysis  of  literature, 
98 — Summary  of  experiments,  99 — Clinical  proofs,  101 — Secondary 
genital  tuberculosis,  101 — Latency  of  the  disease,  102 — Determination 
of  source  of  infection,  102 — Difference  of  opinion  regarding  frequency 
of  primary  and  secondary  infections  of  female  genital  tract,  103 — 
Study  of  cases,  104 — Summary,  105 — Predisposing  causes,  105 — Fre- 
quency, 105 — Histologic  examination,  105. 

VI.    Tuberculosis  of  the  External  Genitalia 109 

Etiology,  109 — Possibility  of  hematogenic  or  lymphogenic  infection, 
109 — Causes,'  109 — Frequency,  109 — Combined  statistics  of  many  in- 
vestigators, no — Varieties,  no — Forms,  ulcerative  and  hypertrophic, 
no — Symptoms,  no — Number  of  cases;  average  age,  in — Relative 
infrequency  of  direct  "inoculation  in  this  locality,  112 — Parturition  as 
causative  agent,  112 — Trauma  a  predisposing  factor,  112 — History  of 
cases,  112 — Appearance  of  ulcerative  variety,  112 — Hypertrophic 
variety,  112 — Tabulation  of  parts  involved,  112— Diagnosis,  112 — Prog- 
nosis, 117 — Method  of  treatment,  117 — Primary  variety,  117 — Secondary, 
118 — Doubtful  cases,  118 — General  treatment,  119 — Tuberculous  non- 
ulcerative hypertrophy  of  the  vulva,  119 — Histologic  examination, 
120 — Tuberculosis  of  Bartholin's  gland,  121 — Tuberculous  ulcers  of 
labia  majora  and  minora,  122 — Histologic  examination,  123 — Study  of 
cases,  124 — Primary  tuberculosis  of  vulva  with  elephantiasis  of  clitoris, 
127 — Secondary  hypertrophic  tuberculosis  of  vulva,  128 — Reports  of 
cases,    129. 

VII.     Tuberculosis  of  the  Vagina 140 

First  authentic  case  of  vaginal  tuberculosis  recorded,  140 — Anatomic 
relationship  existing  between  external  genitalia  and  vagina,  140 — 
Histologic  similarity,  140 — Etiology,  140 — Symptoms,  141 — Experimen- 
tation tending  to  show  that  trauma  and  irritation  are  important  pre- 
disposing factors  in  implantation  form,  141 — Varieties,  142 — Ulcerative 
appearance,  142 — Miliary  form,  142 — Hypertrophic,  142 — Characteris- 
tics, 143 — Syphilis,  malignant  neoplasms,  chancroid,  gonorrhea,  noma 
and  diphtheria  differentiated,  143 — Cases  cited,  144 — Primary  tuberculo- 
sis of  vagina  and  vulva,  145 — Histologic  examination,  145 — Cases  col- 
lected by  Chaton  and  others,  146. 

VIII.    Tuberculosis  of  the  Cervix 149 

Cases  proved  by  histologic  or  bacteriologic  examinations,  149 — Primary 
and  secondary,  150 — Cases  on  record,  150 — Coincident  tuberculosis  of 
other  parts  of  genital  tract,  150 — Tuberculous  salpingitis  with  or  with- 
out involvement  of  the  corporeal  endometrium  a  common  accompani- 
ment, 150 — Predisposing  causes,  151 — Analysis  of  cases  verified  by 
histologic  or  bacteriologic  examination,  152 — Average  age  arranged  in 
decades,   152 — Classification  of  cervical  lesions,  154 — Ulcerative,  papil- 


CONTENTS  ix 

CHAPTER  pAGE 

lary,  miliary,  and  interstitial,  154 — Analysis  of  cases,  154 — Hemorrhage, 
154 — Pain,  154 — Histologic  examination,  156 — Cases,  160 — Tuberculosis 
of  the  body  of  the  uterus,  182 — Endometritis,  182. 

IX.     Tuberculosis  of  the  Fallopian  Tubes  and  Ovaries 192 

General  considerations,  192 — Fallopian  tubes  and  ovaries  anatomically 
and  symptomatically  considered  together,  192 — Predisposition,  193 — 
Routes  of  transmission,  193 — Histologic  examination,  193 — Factors, 
195 — Analysis  of  cases,  196— Study  of  acute  and  chronic  stages,  198— 
Duration  of  acute  stage,  199 — Characteristics  of  chronic  stage,  200 — 
Other  forms  of  infection,  202 — Tuberculin  an  aid  to  diagnosis,  206 — 
Differential  diagnosis  between  tuberculous,  gonococcal,  streptococcal 
and  inflammatory  disease,  207 — Family  history,  210 — Prognosis,  210 — 
Cases,  211 — Methods  of  treatment,  214. 

X.    Unusual  Manifestations  and  Remote  Complications 224 

Tuberculosis  and  neoplasms,  224 — Ways  of  occurrence,  224 — Etiologic 
relation  to  cancer,  225 — Histologic  similarity  of  certain  forms  of 
tuberculous  salpingitis  to  carcinoma  of  fallopian  tube,  225 — Types,  225 
— Cases  recorded,  225 — Tuberculosis  and  non-malignant  tumors  of  the 
genital  tract,  226 — Accidental  or  coincidental  combinations,  22~ — 
Pseudoneoplasms,  227 — Etiology,  228 — Infection  of  adenomyomata  of 
uterus,  228 — Cases,  228 — Ovarian  cysts,  229 — Histology,  229 — Sum- 
mary, 229 — Tuberculosis  of  uterus  causing  pyometra,  230 — Illustration, 
230 — Tuberculous  tubal  lesions,  230 — Torsion  of  tuberculous  pyosal- 
pinges,  231 — Factors,  232 — Action  of  diaphragm  in  cases,  233 — Rupture 
of  tuberculous  pyosalpinges,  233 — Collected  statistics,  234 — Rupture  of 
pyosalpinx  in  adjacent  hollow  viscera,  235 — Necessity  for  thorough 
pelvic  examination,  236 — Extension  of  tuberculosis  from  pelvic  lesion 
to  other  distinct  areas,  237 — Tuberculous  lesions  in  hernial  sac,  237 — 
Histologic  study,  238— Cases  cited,  239. 

XI.    Pregnancy  and  Tuberculosis 243 

History,  243 — Fertility  of  the  tuberculous,  244 — Frequency,  244 — Phys- 
iology of  pregnancy  bearing  on  course  of  tuberculosis,  245 — Organs 
affected,  246 — Puerperium  and  its  bearing  upon  course  of  tuberculo- 
sis, 248— Strain  of  lactation,  249 — Condition  of  children  of  tuberculous 
mothers,  251 — Infant  mortality,  252 — Influence  of  pulmonary  tuber- 
culosis on  course  of  pregnancy,  253 — Influence  of  pregnancy  on  course 
of  pulmonary  tuberculosis,  254 — Tubercle  bacilli  in  mother's  milk,  259 
— Tuberculin  as  curative  and  diagnostic  agent,  260 — Law  regarding 
marriage  of  tuberculous  persons,  261 — Indication  for  induction  of 
abortion  prior  to  fifth  month,  265 — Results,  266 — Consultation  and  pre- 
caution prior  to  induction  of  abortion,  269 — Choice  of  operation,  270 
— Sterilization,  270 — Anesthetic,  271 — Technic  of  operation  (during  first 
two  months),  271 — Convalescence,  272 — Technic  and  choice  of  opera- 
tion for  emptying  uterus  from  second  to  fifth  month,  272 — Preg- 
nancy after  fifth  month,  274 — Delivery  of  tuberculous  patients.  275 — 
Cesarean  section,  276 — Puerperium  treatment  during  nursing,  278 — In- 
fluence of  pregnancy  upon  tuberculous  lesions  other  than  the  lungs,  278. 

XII.  The  Menstrual  Disturbances  of  Pulmonary  Tuberculosis  .  .  .  284 
General  considerations,  284 — Gassification  according  to  types,  284- — 
Etiology,  285 — Theories  advanced.  286 — Later  observations,  287 — Chief 
indications  for  treatment,  288 — Dysmenorrhea,  289 — Clinical  reports, 
290 — Use  of  tuberculin,  291 — Scanty  menstruation,  291 — Statistics,  292 
— Irregular  scanty  flow,  293 — Amenorrhea,  293 — Cases  studied,  293— 
Menorrhagia,  293 — Vicarious  menstruation,  294 — Periodic  hemoptysis, 
295 — Cases  cited,  295 — Leukorrhea,  295 — Influence  of  menstruation  on 
temperature  in  pulmonary  tuberculosis,  295 — Causes,  296 — Considera- 
tion, 297 — Precautions  instituted,  297. 


CONTENTS 


PAGE 


CHAPTER 

XIII.  Pulmonary  Tuberculosis  and  Operation 300 

Three  distinct  dangers,  300— Choice  of  anesthetic,  300— Classification  of 
pulmonary  tuberculosis  based  on  physical  findings  and  constitutional 
symptoms,  300 — Subdivision  into  groups,  301 — Study  of  different  stages 
of  the  disease,  301— Spinal  anesthesia,  303— Precautions  before  opera- 
tion, 303— Importance  of  expert  anesthetist,  304— Convalescence,  305 
— Results,  305 — Condition  of  pulmonary  lesion  six  or  more  months 
after  operation  performed  under  general  anesthesia,  307 — Statistical 
reports,  307. 

XIV.  Tuberculosis  of  the  Breast 3°9 

Historical,  309 — Histologic  study  of  tuberculosis  of  the  breast,  309 — 
Frequency,  309 — Primary  and  secondary  infection,  310 — Routes  of  in- 
fection, 311 — Additional  foci  of  disease,  312— Predisposing  causes,  312 
— Age  incidence,  312— Statistics,  313— Varieties,  314— Confluent,  314— 
Disseminated,  315 — Physical  manifestations,  315 — Initial  symptoms, 
316 — History  of  cases  noted,  316 — Tuberculosis  of  breast  in  combina- 
tion with  true  neoplasm,  318 — Differential  diagnosis  between  tuber- 
culosis and  certain  cases  of  chronic  pyogenic  mastitis,  318 — Post- 
operative results,  320. 

XV.    Tuberculosis  of  the  Peritoneum 323 

Early  history,  323 — First  authentic  operation  performed  by  Sir  Spencer 
Wells,  Z2i — Primary  and  secondary  tuberculous  peritonitis,  324 — Cases 
studied  with  v;ew  of  determining  primary  lesion,  325 — Routes  of  in- 
fection, 325 — Pathology,  327 — Classification  of  tuberculous  peritonitis, 
329 — Varieties,  329 — Acute  miliary,  ascitic,  fibroplastic  and  suppurative, 
329 — Latent  cases  accidentally  discovered,  331 — Frequency;  special  fre- 
quency among  colored  race,  332 — Variety  of  tubercle  bacillus  causing 
tuberculous  peritonitis,  333 — Division  into  groups,  333 — Histologic 
study,  334 — Difficulties  encountered  in  differentiating  malignancy  from 
tuberculosis,  336— Pseudotuberculosis  of  the  peritoneum,  338 — Methods 
of  treatment,  340 — Operative  complications,  343 — Tuberculosis  in 
hernia,  344 — Reformation  of  ascites  following  operation,  344 — Com- 
parison of  results  of  medical  and  surgical  treatment,  344. 

Index ...     349 


GYNECOLOGICAL 
AND  OBSTETRICAL 
TUBERCULOSIS 


GYNECOLOGICAL  AND 
OBSTETRICAL  TUBERCULOSIS 


CHAPTER  I 

HISTORICAL    SKETCH 

Early  Recognition  of  Tuberculosis — Varieties  of  the  disease — Atrophic,  cachectic,  and 
ulcerative — Practical  knowledge  of  certain  features  of  tuberculosis  held  by 
pre-Hippocratic  writers — History  of  the  disease  reviewed  by  Osier,  and  other 
illustrious  members  of  the  medical  profession — Connection  between  tuberculosis 
nodes  and  phthisis  first  indicated  by  Sylvius  (1695) — Baillie  (1793)  first  to  recog- 
nize tuberculosis  in  organs  other  than  the  lungs — Laennec,  originator  of  stetho- 
scope, recognized  unity  of  scrofulous  lymph  nodes  and  phthisis — Open  air  treat- 
ment recommended  by  Samuel  Morton  (1834) — First  successful  inoculation,  by 
Klencke  (1843) — Various  views  regarding  etiology  of  this  condition — Valuable 
work  of  Furnival  (1842)  and  others — Tubercle  bacillus  discovered  by  Koch — 
Genital  tuberculosis  first  recognized  by  Morgagni — Historical  review  of  genital 
tuberculosis. 

Tuberculosis  was  probably  recognized  many  hundreds  of  years  before 
Christ.  Hippocrates  (B.  C.  460-376)  described  phthisis  and  Colsus 
(B.  C.  30)  wrote  of  three  varieties  of  the  disease  :  atrophic,  cachectic, 
and  ulcerative.  Hippocrates  referred  to  tuberculosis  as  "the  greatest 
and  most  dangerous  disease  and  one  that  proved  fatal  to  the  greatest 
number."  Isocrates  believed  that  tuberculosis  was  contagious,  and  Aris- 
totle mentions  that  the  Greeks  were  of  a  similar  opinion.  Galen  con- 
sidered tuberculosis  to  be  an  ulcerative  process  and  recommended  that 
sufferers  from  this  disease  should  live  in  a  high  altitude.  Some  students 
believe  that  the  curse  pronounced  by  Moses  (about  B.  C.  1500)  for 
disobedience  had  reference  to  tuberculosis  (Leviticus,  26  :  16,  and  Deuter- 
onomy, 28:  22)  and  that  the  laws  recorded  in  the  Talmud  (Mischna, 
B.  C.  500)  indicated  the  recognition  of  tuberculosis  in  cattle.  Osier  1 
states  that  the  title  of  one  of  the  lost  books  of  Democritus.  "On  Those 
Who  Are  Attacked  with  a  Cough  after  Illness,"  probably  indicates  that 
the  pre-Hippocratic  writers  had  practical  knowledge  of  certain  features 
of  tuberculosis. 

The  history  of  tuberculosis  includes  a  host  of  illustrious  names,  only 
a  few  of  which  are  mentioned  here,  as  the  historical  side  of  the  disease 

1 


2  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

has  already  been  so  ably  reviewed  by  Osier,1  Waldenburg,2  Predohl,3 
Johne,4  and  others. 

Sylvius  (1695)  was  the  first  to  indicate  the  connection  which  exists 
between  the  tuberculous  nodes  and  phthisis.  Morton  (1689),  in  his 
excellent  book,  showed  the  prevalence  of  tuberculosis  and  accomplished 
much  towards  obtaining  recognition  for  its  importance  by  the  medical 
profession.  Morgagni  (1682-1771)  regarded  the  disease  in  the  light 
of  an  infection  and  believed  it  dangerous  to  perform  autopsies  upon 
tuberculous  subjects.  Stark  (1785)  accurately  described  miliary  tu- 
bercles. Kortum  (1790),  Baume  (1795),  Huf eland  (1796),  and  Cullen 
(1800)  were  of  the  opinion  that  scrofulous  glands  anteceded  phthisis. 
Baillie  (1793)  was  the  first  to  recognize  tuberculosis  in  organs  other  than 
the  lungs.  Portal  (1780)  and  Vetter  (1803)  coincided  with  Baillie  in  his 
findings.  Laennec  (1819)  recognized  the  unity  of  the  scrofulous  lymph 
node  and  phthisis,  described  the  pathology  as  well  as  the  physical  signs 
present  during  the  various  stages  of  phthisis,  and  originated  the  stetho- 
scope, by  means  of  which  accurate  auscultatory  findings  were  made 
possible.  Samuel  Morton  (1834),  a  student  of  Laennec' s,  in  a  mono- 
graph entitled  "Pulmonary  Consumption,"  recommended  the  open  air 
for  these  patients  and  gave  excellent  therapeutic  advice  regarding  the 
treatment  of  phthisical  patients. 

Klencke  (1843)  performed  the  first  successful  inoculation,  infecting 
a  rabbit  with  tuberculosis  by  an  intravenous  injection.  About  this  time 
various  views  were  held  regarding  the  etiology  of  this  condition. 
Dupuy  (1817)  and  Baron  (1822)  attributed  it  to  hydatids.  Furnival 
(1842)  believed  the  condition  to  be  due  to  deficient  enervation.  Engel 
(1844)  thought  the  disease  was  similar  in  general  character  to  typhoid 
fever,  but  caused  by  a  different  exudate.  Alison  ( 1824),  Glover  ( 1847), 
Simon  (1850),  and  Villemin  (1865)  were  of  the  opinion  that  tubercu- 
losis was  the  result  of  a  specific  infection.  Langhans  (1868),  Schuller 
(1877),  Tappeiner  (1878),  and  others  performed  more  or  less  suc- 
cessful experimental  inoculations,  the  results  of  which  were  finally 
settled  by  the  work  of  Cohnheim  and  Salmonsen  (1879),  who  positively 
reproduced  the  lesion  by  inoculating  the  anterior  chamber  of  a  rab- 
bit's eye. 

Friedlander  (1873),  Koster  (1873),  and  Weigert  (1879-1882)  con- 
tributed valuable  work.  Aufrecht  (1881)  and  Baumgarten  (1883),  in- 
dependently of  Koch,  described  bacilli  in  the  centers  of  tubercles,  but  did 
not  prove  that  they  were  the  infecting  and  active  agents. 

The  tubercle  bacillus  is  the  cause  of  tuberculosis.  For  many  years, 
prior  to  the  discovery  of  the  tubercle  bacillus  by  Koch  5  in  1882  and 


HISTORICAL  SKETCH  3 

public  announcement  thereof  on  March  24,  before  the  Physiological  So- 
ciety of  Berlin,  the  infectious  nature  of  the  disease  was  suspected.  In 
1843,  Klencke  successfully  accomplished  the  transmission  of  the  disease, 
employing  tuberculous  material,  and  in  1865  Villemin  6  did  likewise. 
Baumgarten  7  also  reported  the  presence  of  what  were  probably  tubercle 
bacilli  in  tissue,  but  had  not  proved  the  pathogenesis  of  the  organism 
by  inoculation. 

GENITAL  TUBERCULOSIS 

Morgagni  8  was  the  first  to  recognize  genital  tuberculosis.  This 
observer,  upon  performing  an  autopsy  upon  a  girl  of  twenty  years  of 
age  who  had  died  of  tuberculous  peritonitis,  found  the  uterus  and 
adnexa  filled  with  caseous  material  and  believed  that  these  organs  were 
the  primary  focus  of  the  disease.  The  importance  of  Morgagni's  ob- 
servation was  apparently  not  recognized,  for  no  further  mention  is  found 
of  genital  tuberculosis  until  the  reports  of  Reynaud  9  and  Senn  10  in 
1 83 1.  Reynaud  described  two  cases  of  genital  tuberculosis  occurring  in 
phthisical  patients.  Twelve  years  later  Louis  u  also  recorded  cases.  In 
1853  Virchow 12  described  genital  lesions  which  were  secondary  to 
tuberculosis  of  the  urinary  tract. 

In  reviewing  the  literature  of  this  period,  cognizance  must  be  taken 
of  the  fact  that  the  etiology  of  tuberculosis  was  unknown  and  even  its 
pathology  was  not  well  understood,  so  that  as  a  result  many  lesions 
were  attributed  to  this  variety  of  infection  which  are  now  known  to 
have  no  connection  with  tuberculosis.  Thus  we  find  Waller  13  describing 
uterine  myomata  and  writing  that  they  were  analogous  to  the  "fleshy 
tubercle  of  the  womb"  described  by  William  Hunter.  Similar  erroneous 
observations  were  made  by  Diintzer 14  and  Osiender,15  while  Lis- 
franc  16  and  Thiry  17  believed  Nabothian  cysts  to  be  of  tuberculous  origin 
and  remarked  upon  the  ease  with  which  this  form  of  tuberculosis  was 
cured.  Boivin  and  Duges 18  describe  tuberculous  adnexitis  and  give 
an  excellent  illustration  of  a  specimen.  As  time  went  on,  a  greater 
number  of  cases  were  recorded  in  the  literature  and  a  more  accurate 
comprehension  of  the  pathology  and  symptomatology  of  genital  tubercu- 
losis became  prevalent.  Kiwisch,19  Giel,20  and  Paulsen  21  contributed 
valuable  information  on  this  subject.  Hegar's  22  important  work  ap- 
peared in  1886.  Williams,23  in  his  admirable  historical  review  of 
genital  tuberculosis,  remarks  that  an  interesting  feature  of  the  history 
of  this  condition  is  that  for  so  long  the  ovaries  were  not  considered 
receptive  to  the  infection.    Even  such  close  observers  as  Virchow  12  and 


4     GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Rokitansky  24  were  of  this  opinion,  and  as  late  as  1880  Brissaud  25  stated 
that  there  was  not  a  single  specimen  of  tuberculosis  of  the  ovary  in  the 
Museum  of  the  College  of  France.  Koch's  discovery  of  the  tubercle 
bacillus  added  stimulus  to  the  study  of  genital  tuberculosis  and  made  it 
possible  to  positively  diagnose  the  condition. 

In  1883  Babes  26  demonstrated  tubercle  bacilli  in  the  vaginal  dis- 
charge in  a  case  of  rectovaginal  fistula.  This  is  the  first  authentic  record 
of  such  findings.  Hegar's  masterly  monograph  entitled  "Die  Entstehung, 
Diagnose  und  chirurgische  Behandlung  der  Genital  Tuberculose  des 
Weibes"  (Stuttgart),  which  appeared  in  1886,  and  the  work  of 
Chiari,27'  Bierfreund,28  Baumgarten,29  Kronig,30  Bandl,31  Martin,32,  33 
Schauta,34  and  later  the  valuable  contributions  by  Kelly  35  and  Osier  3G 
and  by  many  others  appeared  in  succession  and  have  done  much  towards 
elucidating  the  pathology,  symptomatology,  and  treatment  of  tubercu- 
losis of  the  female  genitalia. 


LITERATURE 

1.  Osler,  Sir  W.     Tuberculosis,  edited  by  A.  C.  Klebs,  1909. 

2.  Waldenburg,  L.     Die  Tuberculose,  die  Lungenschwindsucht,  und 

Scrofulose.     Berlin,  1869,  Hirshwald. 

3.  Predohl,   A.     Die   Geschichte   der   Tuberkulose.     Hamburg   and 

Leipzig,  1888,  Voss.    p.  482. 

4.  Johne,    A.     Die    Geschichte    der    Tuberkulose    mit    Besonderen 

Berikksichtigung  der  Tuberkulose  des  Rindes.     Leipzig,  1883, 
Vogel.    p.  88. 

5.  Koch,  R.     Berl.  Klin.  Woch.     1882,  19:221.     Mitth.  a.  d.  Kais. 

Gesundheitsamt,  1884. 

6.  Villemin.     Gaz.  Hebd.  de  Med.     1865.    2s.,  5. 

7.  Baumgarten.     Virch.  Arch.,  82.     Also  Centrbl.  f.  d.  Med.  Wiss. 

1882.    20:257. 

8.  Morgagni.     De  Sedibus  et  Causis  Morborum  Epistolae  38.     34. 

9.  Reynaud,  M     Arch.  Gen.  de  Med.      1831.     36:486. 

10.  Sexn.    Arch.  Gen.  de  Med.     1831.    37:282. 

11.  Louis.     Recherches  sur  la  Phthisic     Paris,  1843. 

12.  Virchow.    Virch.  Arch.     1853.     5  404. 

13.  Waller.     Analekten  fur  Frauenkrankheiten.     1842.     3  493. 

14.  Duntzer.     Neue  Ztschr.  f.  Geb.     1840.     8:219. 

15.  Osiender.    Hann.  Ann.  f.  Ges.  Heilk.     1840.     5:108. 

16.  Lisfranc.    Clin.  Chiv.  de  la  Pitie.     1842,  2:661. 


HISTORICAL  SKETCH  5 

17.  Thiry.    Presse  Med.  Beige.     1852.    4:1. 

18.  Boivin  et  Duges.     Traite  pratique  des  maladies  de  l'uterus  et  de 

ses  annexes  (2d  ed.).     1834.    Plate  16. 

19.  Kiwisch.     Klin.  Vort.     1847,2:400. 

20.  Giel.     Inaug.  Dissert.,  Erlangen,  1851. 

21.  Paulsen.     Schmidt's  Jahrb.     1853.    80:222. 

22.  Hegar.     Die  Entsiehung,  Diagnose,  und  Chirurgische  Behandlung 

der  Genital  Tuberculose  des  Weibes.     Stuttgart,  1886. 

23.  Williams,  J.  W.     Johns  Hopkins  Hospital  Reports.    1893.    3  :^7- 

24.  Rokitansky.      Lehrbuch   der    Pathologischen    Anatomic.      1861. 

3  444- 

25.  Brissaud,  E.     Arch.  Gen.  de  Med.     1880.     146:129. 

26.  Babes,  V.     Orvosi  Hetil.     Budapest,  1883.    27:163. 

27.  Chiari,  H.     Vrtljschr.  f.  Derm.    Vienna,  1886.     13:341. 

28.  Bierfreund,  M.     Ztschr.  f.  Geb.  u.  Gyn.      1888.      15:425. 

29.  Baumgarten,  P.     Ztschr.  f.  Klin.  Med.     1885.     9:93. 

30.  Kronig.     Centrbl.  f.  Chir.     1884.     11:81. 

31.  Bandl.     Billroth-Liicke  Handbuch  der  Frauenkrankheiten.     1886. 

b.  2. 

32.  Martin,  A.     Cong.  Per.  Internat.  d.  Sc.  Med.,  Sec.  Obst.  and  Gyn. 

Copenhagen,  1886.     2  :56. 

33.  Martin,    A.      Pathologie   und   Therapie    der    Frauenkrankheiten. 

Vienna  and  Leipzig,  1887,  Urban  and  Schwarzenberg. 

34.  Schauta.    Arch.  f.  Gyn.     1888.    33:27. 

35.  Kelly,  H.  A.     Johns  Hopkins  Hospital  Reports.      1890.     2:201. 

36.  Osler,  Sir  W.     Johns  Hopkins  Hospital  Reports.     1890.     2:67. 


CHAPTER  II 

THE  DIAGNOSIS  OF  TUBERCULOSIS  OF  THE  FEMALE  GENITAL  TRACT 
BY   LABORATORY    METHODS 

Cervix  and  lower  genital  tract — Methods  of  treatment — Curettage — Value  of  ex- 
amination of  leukorrheal  discharge  in  tuberculous  endometritis — Organisms  likely 
to  be  mistaken  for  the  tubercle  bacillus — Smegma  bacilli — Study  of  morphology, 
and  of  staining  by  ordinary  methods — Grethe  method — Czaplewski  method — 
Etiology  of  smegma  bacilli — Bacillus  leprae — Resemblance  to  tubercle  bacillus — 
Differentiation — Cultural  methods  and  clinical  study — Animal  inoculation  almost 
positively  diagnostic — Danger  of  mistaking  malignant  neoplasms  for  certain  forms 
01  tuberculosis — Diagnostic  use  of  tuberculin  in  gynecological  conditions — Sum- 
mary of  histologic  examination. 


CERVIX  AND  LOWER  GENITAL  TRACT 

In  lesions  of  these  localities  biopsy  offers  an  easy  and  almost  certain 
means  of  diagnosis  and,  if  this  method  is  employed,  the  histologic  as 
well  as  the  bacteriologic  examination  is  available.  If  the  lesions  be  ulcer- 
ative or  friable,  a  light  curettage  may  be  performed  and  the  material 
thus  obtained  similarly  employed.  An  anesthetic  is  not  necessary.  Curet- 
tage is  of  little  value  in  the  hypertrophic  varieties  of  tuberculosis,  such 
as  may  be  encountered  in  the  vagina  and  external  genitalia,  unless  there 
be  loss  of  continuity  of  the  surface.  For  lesions  within  the  cervical 
canal  or  for  the  ulcerative  or  hypertrophic  varieties  of  tuberculosis  of 
the  cervix,  curettage  is  of  distinct  value. 

For  those  cases  in  which  biopsy  or  curettage  is  not  advisable,  or  as 
a  preliminary  measure,  the  discharge  may  be  examined.  For  this  pur- 
pose the  parts  should  be  thoroughly  cleansed  and  a  dressing  or  tampon 
applied.  Some  hours  later  the  exudate  which  has  collected  upon  the 
under  surface  of  the  dressing  may  be  examined. 

The  most  frequent  site  for  tuberculosis  in  the  female  genital  tract  is 
the  fallopian  tubes.  Tuberculous  salpingitis,  except  in  the  early  stages, 
usually  occludes  the  inner  portion  of  the  tube,  so  that  the  tubal  contents 
do  not  gain  free  access  to  the  uterine  cavity.  Even  if  the  uterine  ostium 
of  the  tube  is  patulous,  the  opening  is  generally  so  small  that  but  little 

6 


DIAGNOSIS  OF  TUBERCULOSIS  BY  LABORATORY  METHODS       7 

of  the  tubal  exudate  escapes,  and  that  which  does  is  likely  to  be  mixed 
with  such  a  relatively  large  amount  of  uterine  and  cervical  secretion  that, 
by  the  time  it  is  obtainable  at  the  external  os,  the  demonstration  of  the 
tubercle  bacillus  is  extremely  difficult.  Although  the  organism  is  found, 
it  is  impossible  to  determine  whether  it  is  from  the  tube  or  from  the 
endometrium.  However,  the  latter  is  a  comparatively  unimportant  point, 
inasmuch  as  when  the  corporeal  endometrium  is  involved  the  tubes  are 
nearly  always  affected.  To  obtain  material  for  examination,  the  vagina 
and  portio  vaginalis  should  be  thoroughly  cleansed  and  two  close  fitting 
tampons  applied  to  the  cervix.  The  secretion  thus  obtained  on  the  upper 
surface  of  the  upper  tampon  after  the  latter  has  been  in  place  for  twenty- 
four  hours  is  utilized.  Immediately  after  removal  of  the  tampon  addi- 
tional secretion  should  be  secured  from  within  the  cervical  canal  by  means 
of  a  sterile  platinum  loop. 

Cummins  1  has  reported  good  results  with  this  method.  Negative 
results  do  not  exclude  the  tuberculous  origin  of  the  disease,  particularly 
when  the  tubes  alone  are  involved. 

In  tuberculous  endometritis  the  examination  of  the  leukorrheal  dis- 
charge secured  by  this  method  is  of  definite  value,  and,  whereas  too  much 
stress  should  not  be  paid  to  negative  results,  the  proportion  of  cases  in 
which  it  is  possible  to  demonstrate  the  tubercle  bacillus  is  considerable. 
In  the  selection  of  material  for  examination,  especial  attention  should  be 
given  to  cheesy  particles,  for  it  is  in  these  that  the  organisms  are  most 
frequently  found.  In  cases  of  tuberculous  endometritis,  tubercle  bacilli 
are  more  numerous  in  the  discharge  immediately  after  the  cessation  of  a 
menstrual  period. 

Curettage  of  the  endometrial  cavity  and  the  examination  of  the  curet- 
tings  is  naturally  a  much  more  certain  method  of  diagnosis  than  is  the 
examination  of  the  secretion,  and  in  some  cases  is  a  desirable  procedure, 
which  may  be  employed  for  diagnostic  purposes  as  well  as  for  other 
reasons.  Occasionally  the  removal  of  one  or  two  strips  of  endometrium 
by  means  of  a  small  curette  for  diagnosis  is  a  justifiable  operation.  As  a 
general  rule,  however,  curettage,  unless  immediately  followed  or  preceded 
by  an  abdominal  section,  is  inadvisable.  A  salpingitis  is  nearly  always 
present,  and  curettage  alone  is  likely  to  be  the  means  of  setting  up  an 
exacerbation  of  the  infection. 

When  depending  upon  the  staining  of  the  tubercle  bacillus  in  prepa- 
rations of  secretion  obtained  from  the  cervix  or  lower  genital  tract,  the 
great  difficulty  is  to  differentiate  the  tubercle  bacillus  from  other  organ- 
isms which  may  be  present  and  which  are  morphologically  and  tincto- 
rially  similar.     A  number  of  organisms  which  possess  nearly  the  same 


8     GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

size,  shape  and  staining  properties  may  be  encountered.     Chief  among 
these  is  the  smegma  bacillus. 

Organisms  Likely  to  Be  Mistaken  for  the  Tubercle  Bacillus. — 
Smegma  Bacilli. — These  organisms  morphologically  and  by  the  ordi- 
nary staining  methods  closely  resemble  tubercle  bacilli.  The  normal 
habitat  of  the  smegma  bacillus  is  in  the  external  genitalia  and  it  is  espe- 
cially common  in  the  interlabial  folds  in  women  and  around  the  corona 
of  the  glans  in  men.  It  is  also  found  in  the  skin  between  the  thighs  and 
is  not  infrequent  in  the  vagina,  especially  the  lower  portion.  Gottstein,2 
Ritter,3  Labbs,4  Alvarez  and  Taval,5  Matterstock,6  Klemperer,7  and 
others  have  demonstrated  the  organism  in  various  localities  on  the  skin 
surface  of  the  body,  around  the  natural  opening,  and  even  upon  the  coat- 
ing of  the  tongue  and  teeth.  The  bacillus  is  of  frequent  occurrence  in 
the  urine  (especially  in  specimens  passed  voluntarily)  and  in  the  feces. 
It  appears  in  especially  large  numbers  in  any  area  where  normal  skin 
secretions  are  allowed  to  collect,  and  has  been  frequently  observed  about 
the  umbilicus,  in  the  cerumen  of  the  ear,  about  the  teeth,  etc.  In  this 
respect  its  occurrence  is  somewhat  dependent  on  the  degree  of  cleanliness 
of  the  patient.  Regarding  the  frequency  with  which  the  smegma  bacillus 
occurs  in  the  genital  tract,  Brereton  and  Smith,8  in  126  insane  or  un- 
cleanly patients,  found  red  staining  bacilli  in  85  (67.5  per  cent)  after 
decolorization  by  25  per  cent  sulphuric  acid,  while  they  occurred  in  only 
19  (22  per  cent)  of  these  patients  after  methylene  blue  had  been  employed 
as  a  counter  stain  after  decolorization.  They  were  present  in  13  per 
cent  after  decolorization  by  acid  alcohol  or  Labarraque's  solution.  In  a 
second  series  of  twenty  ordinary  cases  these  authors  found  smegma 
bacilli  in  13,  or  65  per  cent,  after  the  use  of  sulphuric  acid  only,  and 
2  or  1  per  cent  after  counter  staining.  Young  and  Churchman,9  in  24 
tests,  found  smegma  bacilli  present  in  46  per  cent  of  cases.  As  this  or- 
ganism is  so  frequently  present  in  the  neighborhood  of  the  external 
genitalia,  its  differentiation  from  the  tubercle  bacillus,  when  studying 
material  from  this  locality,  is  of  extreme  importance.  The  smegma 
bacillus  is  non-pathogenic.  In  earlier  times  a  number  of  operations  have 
been  performed  under  a  misconception  because  of  a  lack  of  knowledge 
upon  this  point  (Labbs,4  Kronig,10  Bunge  and  Trentenrath  n). 

A  study  of  the  morphology  and  of  staining  by  the  ordinary  methods, 
employing  inorganic  acids  as  decolorizers,  is  useless  as  far  as  differentia- 
tion between  the  tubercle  bacillus  and  smegma  bacillus  is  concerned, 
although  it  is  claimed  by  some  observers  that  the  smegma  bacillus  is 
slightly  shorter  than  the  tubercle  bacillus.  Certain  special  stains  are, 
however,  moderately  reliable.     Smegma  bacilli  are  decolorized  somewhat 


DIAGNOSIS  OF  TUBERCULOSIS  BY  LABORATORY  METHODS      9 

more  easily  than  are  tubercle  bacilli  and  may  be  decolorized  with  abso- 
lute alcohol,  although  Moller  12  believes  them  not  only  alcohol,  but  acid 
proof,  and  admits  no  tinctorial  difference  from  the  tubercle  bacillus. 
Brown  13  states  careful  work  to  have  shown  that  no  staining  methods 
differentiate  tubercle  from  smegma  bacilli :  he  recommends  Petroff's 
medium  as  a  differentiating  agent  for  tubercle  and  smegma  bacilli. 

Bunge  and  Trentenroth11  Method. — 1.  Fixation  of  smears  by  abso- 
lute alcohol  for  three  hours. 

2.  Five, per  cent  chromic  acid  for  at  least  fifteen  minutes. 

3.  Wash,  in  several  changes  of  water. 

4.  Stain  in  carbol  fuchsin,  in  usual  manner. 

5.  Decolorize  with  dilute  sulphuric  acid  for  three  minutes,  or  pure 
nitric  acid  for  one;  or  two  minutes. 

6.  Secondary  decolorization  combined  with  secondary  staining  in  a 
concentrated  alcoholic  solution  of  methylene  blue  for  at  least  five  minutes. 

Result:  Bunge  and  Trentenroth  state  that  in  all  cases  smegma 
bacilli  were  decolorized,  and  only  rarely  did  they  find  one  or  more  bacilli 
reddish  violet,  but  by  no  means  so  intense  (tubercle  bacilli  from  sputum 
only  were  employed  as  controls ) . 

Grethe  14  Method. — The  preparation  is  stained  in  the  ordinary  man- 
ner with  carbol  fuchsin,  washed,  and,  without  further  decolorization,  is 
treated  with  a  concentrated  solution  of  methylene  blue  in  absolute  alcohol. 
The  tubercle  bacilli  remain  red,  while  the  smegma  bacilli  are  blue. 
Weichselbaum  15  reported  excellent  results  with  this  method. 

Czaplewski 16  Method. — Treat  and  stain  in  the  usual  manner  with 
heated  carbol  fuchsin.  The  excess  of  the  fluid  is  drained  off  and  the  prep- 
aration immersed  for  five  minutes  in  fluorescein  methylene  blue  and  then 
in  concentrated  alcoholic  solution  of  methylene  blue  for  one*  half  to  one 
minute  and  rapidly  washed  in  fresh  water  and  mounted. 

In  staining  smear  preparations  for  the  purpose  of  differentiating  the 
smegma  bacillus,  it  is  wise  to  place,  a  few  tubercle  bacilli  of  known  au- 
thenticity upon  the  cover  glass,  some  distance  from  the  material  for  ex- 
amination, as  a  control.  If  urine  is  to  be  examined,  a  catheterized  speci- 
men, the  external  urinary  meatus  having  first  been  carefully  cleansed  in 
order  to  avoid  contamination,  should  be  utilized.  As  has  been  stated, 
biopsy  or  inoculation  methods  offer  a  more  certain  means  of  diagnosis 
than  does  the  microscopic  examination  and  smear  preparation  from  the 
genital  tract  when  tuberculosis  is  suspected,  and  should  be  resorted  to  in 
all  doubt  fid  eases. 

All  investigators  agree  on  the  non-pathogenic  character  of  the  smegma 
bacillus,  and  animal  inoculation  can  thus  be  safely  depended  upon  in  all 


io         GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

doubtful  cases.  Young  and  Churchman  9  insist  that  the  presence  of  the 
smegma  bacillus  cannot  be  excluded  from  specimens  of  urine  by  cleans- 
ing of  the  external  genitalia,  but  that  urethral  irrigation  must  be  fre- 
quently undertaken.  Brereton  and  Smith  8  believe  that  no  meihod  of  dif- 
ferentiating the  tubercle  bacillus  from  the  smegma  bacillus  by  staining 
is  entirely  adequate  for  all  cases,  and  that  the  successful  cultivation  of 
the  latter  organisms  is  open  to  question. 

The  smegma  bacillus  was  first  cultivated  by  Czaplewski.17  Novey  18 
recommends  the  following  media:  Agar-agar  is  cooled  to  500  C.  and 
mixed  with  a  small  quantity  (about  2  c.cm.)  of  fresh,  sterile  human 
blood.  The  mixture  is  poured  into  Petri  dishes  and  placed  in  the  in- 
cubator at  370  C.  for  twenty-four  to  forty-eight  hours. 

Subcultures,  according  to  Moller,12  may  be  grown  upon  glycerin 
agar-agar.  The  organism  may  also  be  cultivated  in  bouillon,  potato,  or 
glycerin  agar,  at  2>7°  C. ;  upon  the  latter,  colonies  appear  in  minute, 
whitish  or  yellowish  scale-like  dots,  which  later  become  somewhat  rounded 
and  possess  a  soft  velvety  or  corrugated  surface.     The  growth  is  slow. 

Bacillus  Leprae. — This  organism  morphologically  closely  resem- 
bles the  tubercle  bacillus.  The  frequent  intracellular  position  and  often 
parallel  or  package-like  arrangement  under  such  circumstances,  and  the 
tendency  which  they  possess  to  occupy  lymphatic  spaces,  are  points  aiding 
in  their  differentiation.  They  stain  somewhat  more  readily  than  do  the 
tubercle  bacilli.  None  of  these  characteristics  is,  however,  sufficiently 
marked  to  positively  differentiate  these  two  organisms,  and  cultural 
methods  and  a  clinical  study  of  the  case  are  required  for  a  positive  diag- 
nosis. The  bacillus  leprae  is  cultivated  upon  artificial  media  with  great 
difficulty  and  some  doubt  exists  as  to  whether  it  has  ever  been  grown 
freely  upon  the  media  usually  employed  for  the  cultivation  of  the  tubercle 
bacillus ;  indeed,  Jordan  19  states  that  saprophytic  growth  on  the  part  of 
the  leprosy  bacillus  is  entirely  unknown.  On  the  other  hand,  McFar- 
land  20  states  that  in  cultures  there  is  a  delicate  filamentous  arrangement 
of  the  leprae  bacilli,  especially  where  they  have  become  accustomed  to 
a  saprophytic  existence. 

There  is  a  large  number  of  other  acid  proof  bacteria  (about  forty) 
which,  however,  as  a  rule,  can  be  easily  differentiated  from  the  tubercle 
bacillus.  Such  organisms  have  been  isolated  from  butter  (Petri,21  Rabi- 
nowitsch,22  Korn23)  and  hay  (Moller12).  In  some  cases,  it  is  almost 
impossible  to  differentiate  these  organisms  from  the  tubercle  bacillus, 
although  the  rapid  growth  of  the  hay  and  butter  bacilli  in  artificial  media, 
at  about  200  C,  is  their  chief  differential  point.  As  a  rule,  the  clinical 
picture  is  sufficient  to  differentiate  the  organism;  however,  Frankel,24 


DIAGNOSIS  OF  TUBERCULOSIS  BY  LABORATORY  METHODS     n 

Rabinowitsch,22  and  Marzinowski  25  have  demonstrated  these  organisms 
in  pathologic  conditions  in  the  lungs.  The  possibility  of  these  bacilli 
being  present  in  conjunction  with  the  tubercle  bacillus  must  also  be  taken 
into  consideration.  Leprosy  is  a  rare  disease  in  this  climate,  and  the 
clinical  symptoms  are  usually  sufficient  upon  which  to  differentiate  the 
disease  from  tuberculosis  of  the  genital  tract. 

As  can  be  seen  from  the  foregoing,  ways  of  demonstrating  the 
tubercle  bacillus  in  the  discharge  by  staining  methods  are  open  to  doubt. 
The  finding  of  characteristic  organisms  in  the  tissue  may  be  considered 
moderately  reliable.  When,  however,  sufficient  tissue  is  obtainable  to 
demonstrate  the  organism  in  it,  a  histologic  diagnosis  which  is  equally 
reliable  is  usually  possible.  Tubercle  bacilli,  in  certain  forms  of  tuber- 
culosis and  in  certain  stages  of  the  disease,  are  present  only  in  small  num- 
bers, and  their  demonstration  consequently  is  difficult,  whereas,  on  the 
other  hand,  diagnosis  by  histologic  examination  is  usually  easy.  Animal 
inoculation  offers  an  almost  positive  method  of  diagnosis.  It  is  more  cer- 
tain when  ground  up  particles  of  the  suspected  tissue  are  employed  than 
when  only  the  exudate  is  utilized.  The  disadvantage  of  animal  inocula- 
tion is  the  time  required.    Three  or  four  guinea  pigs  should  be  inoculated. 

The  danger  of  mistaking  malignant  neoplasms  for  certain  forms  of 
tuberculosis,  particularly  those  occurring  in  the  cervix  and  external  geni- 
talia, should  be  taken  into  consideration  when  obtaining  tissue  for  diag- 
nosis. For  fear  of  disseminating  a  malignant  tumor,  it  is  therefore  ad- 
visable, when  performing  biopsy,  to  employ  the  cautery  knife  heated  to 
a  dull  red,  or  the  cut  edges  of  the  wound  may  be  immediately  seared 
following  the  removal  of  the  suspected  tissue.  Rapid  diagnosis  is  an 
important  factor  in  these  cases  and  is  an  additional  reason  for  the  em- 
ployment of  histologic  means,  rather  than  waiting  for  the  slower  inocula- 
tion method.  The  latter  may,  however,  be  utilized  with  advantage  as 
an  auxiliary  to  the  histologic  examination,  and  is  especially  valuable 
when  the  rare  hypertrophic  variety  of  tuberculosis  of  the  external  geni- 
talia is  suspected. 

The  Diagnostic  Use  of  Tuberculin  in  Gynecological  Conditions. 
— Pankow 26  states  that,  in  the  cases  examined  by  him,  he  observed 
focal  reactions  in  the  absence  of  tuberculous  foci.  In  three  cases  of  pelvic 
inflammatory  disease,  of  non-tuberculous  origin,  he  obtained  a  focal  re- 
action, but  in  one  of  these  the  local  symptoms  may  have  been  caused  by 
menstruation.  Sahli 27  has  emphasized  the  fact  that  sensitiveness  is  in- 
creased in  the  premenstrual  period.  Beer  28  asserts  that  such  focal  reac- 
tions in  non-tuberculous  cases  must  be  exceptional.  Mohr  29  is  of  the 
opinion  that  a  negative  response  excludes  tuberculosis;  but  Beer  thinks 


12  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

a  general,  plus  a  focal,  response  is  practically  invariably  due  to  a  focal 
tuberculosis,  and  that  such  a  response  locates  the  diseased  area.  A  gen- 
eral, minus  a  focal,  response  is  of  no  practical  value,  as  the  most  careful 
examination  cannot  exclude  tuberculosis  in  other  parts  of  the  body,  which 
may  give  the  general  reaction.  Servaes  30  says  that  Moller  made  20,000 
injections  without  any  bad  effects. 

In  speaking  of  pulmonary  tuberculosis,  Brown  31  states  that  the  dan- 
ger from  the  proper  use  of  the  tuberculin  test  is  slight,  but  in  some  un- 
suitable cases  very  real.  Shattuck  32  believes  the  subcutaneous  test  the 
most  reliable  and  has  never  seen  untoward  results  beyond  a  disturbance 
of  two  or  three  days,  except  in  one  case  of  Addison's  disease.  Jane- 
way  33  has  also  observed  a  fatal  issue  from  the  use  of  this  test  in  Addi- 
son's disease.  Koplik  34  makes  an  almost  routine  use  of  the  cutaneous 
von  Pirquet  test  in  children. 

The  author  has  had  no  personal  experience  with  the  use  of  tuberculin 
as  a  diagnostic  agent  in  patients  suffering  from  gynecologic  lesions.  It 
would  appear  that  its  use  is  not  entirely  free  from  danger  and  the  results 
obtained  are  somewhat  uncertain.  It  is  probably  of  little  or  no  practical 
value.  The  fact  that  tuberculosis  of  the  female  genital  tract  and  peri- 
toneum is  generally  secondary  to  tuberculosis  elsewhere  in  the  body  and 
that  pulmonary  or  other  forms  of  tuberculosis  are  frequent  and  often 
quiescent  greatly  nullifies  the  value  of  the  tuberculin  test.  The  same  may 
be  said  regarding  the  von  Pirquet  and  the  complement  fixation  test. 

Summary  of  Histologic  Examination. — This  method  offers  a 
rapid  and  quick  method  of  diagnosis.  The  various  forms  of  tuberculosis 
can  nearly  always  be  diagnosed  by  it  with  certainty  and  the  possibility 
of  malignancy  can  be  easily  determined.  As  a  supplement  to  it,  a  part  of 
the  tissue  may  be  utilized  for  animal  inoculation,  and  this  is  a  valuable 
aid,  but  has  the  distinct  disadvantage  of  being  time  consuming,  a  point 
which  is  especially  to  be  avoided  in  those  cases  in  which  the  possibility  of 
malignancy  cannot  be  excluded.  With  light  curettage,  such  as  may  be 
performed  upon  ulcerative  lesions  of  the  cervix  or  lower  genital  tract, 
enough  tissue  may  sometimes  be  obtained  for  a  histologic  examination. 
The  employment  of  such  material  for  animal  inoculation  is  of  distinct 
value.  The  staining  of  secretions,  often  as  a  preliminary  method,  is  not 
without  value;  negative  results  do  not  exclude  with  certainty  the  possi- 
bility of  the  tuberculous  character  of  the  lesion,  and,  owing  to  the  simi- 
larity of  the  smegma  bacillus  to  the  tubercle  bacillus,  positive  results 
cannot  be  absolutely  relieA  upon. 


DIAGNOSIS  OF  TUBERCULOSIS  BY  LABORATORY  METHODS      13 

LITERATURE 

1.  Cummins,  H.  H.     Phys.  and  Surg.     1912.    34:202. 

2.  Gottstein.     Fortsch.  der  Med.     1886.    4:252. 

3.  Bitter.     Virch.  arch.     1886.     106:209. 

4.  Laabs.     Inaug.  dissert,  Freiburg,  1894. 

.  5.     Alvarez  and  Taval.     Arch,  de  Physiol.  Norm,  et  Path.     1885. 
No.  7. 

6.  Matterstock.     Mitth.  a.  d.  Med.  Klin.  Wurzburg.     1885.    No.  6. 

7.  Klemperer.     Deutsch.  Med.  Woch.     1885.     No.   11. 

8.  Brereton,  C.  E.,  and  Smith,  K.  W.     Am.  Jr.  Med.  Sc.     1914. 

148  :267. 

9.  Young,  H.  H.,  Churchman,  J.  W.     Am.  Jr.  Med.   Sc.     1905. 

130:52. 

10.  Kronig.    Deutsch.  Med.  Woch.     1894.    No.  43. 

11.  Bunge    und    Trentenroth.      Fortschr.    d.    Med.      1896.      No. 

14. 

12.  Moller.     Centrbl.  f.  Bakt.  Par.  Inf.     1902.    29 :278. 

13.  Brown,  L.     Jr.  Am.  Med.  Assoc.     1915.     64:886. 

14.  Grethe.    Fortschr.  d.  Med.     1896.    No.  9. 

15.  Weichselbaum.    Fortschr.  d.  Med.     1896.     No.  9. 

16.  Czaplewski,  E.     Die  Untersuchung  der  Auswarfs  auf  Tuberkel- 

bacillen.     Jena,  1891,  Fischer. 

17.  Czaplewski,  E.    Munch.  Med.  Woch.     1897. 

18.  Now.     Laboratory  Work  in  Bacteriology.     1899. 

19.  Jordan,  E.  O.     A  Text  Book  of  General  Bacteriology.     Philadel- 

phia and  London.     1908.     p.  1358. 

20.  McFarland.      A   Textbook  Upon   the   Pathologic    Bacteria   and 

Protozoa.     Philadelphia  and  London.     1912.     p.  763. 

21.  Petri.     Arb.  a.  d.  Kais.  Geshtamt.     1897. 

22.  Rabinowitsch.     Deutsch.   Med.   Woch.      1900.     26:258.     Also. 

Ztschr.  f.  Hyg.  u.  Inf.     1897. 

23.  Korn.     Centrbl.  f.  Bakt.  Par.  Inf.     1899. 

24.  Frankel.    Berl.  Klin.  Woch.     1898.    35:246,880. 

25.  Marzinowski.    Centrbl.  f.  Bakt.  Par.  Inf.     1901.    28:39. 

26.  Pankow.     Centrbl.  f.  Gyn.     1907. 
2.y.     Sahli.     Tuberkulinbehandlung.     1910. 

28.  Beer,  E.     N.  Y.  Med.  Rec.     84:652. 

29.  Mohr.     Munch.  Med.  Woch.     1906. 

30.  Servaes.     Beitr.  z.  Klin.  d.  Tuberk.     1904.    u.  2. 


14  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

31.  Brown,  L.    Tr.  Assoc.  Am.  Phys.     1911.    26:22. 

32.  Shattuck,  F.  C.     Tr.  Assoc.  Am.  Phys.     1911.    26:31. 

33.  Janew ay.    Tr.  Assoc.  Am.  Phys.     1911.    26:31. 

34.  Koplik.    Tr.  Assoc.  Am.  Phys.    191 1.    26:31. 


CHAPTER  III 

PATHOLOGY 

Two  distinct  forms  of  genital  tuberculosis,  ulcerative  and  hypertrophic— Histologic 
examination  of  ulcerative  form — Hypertrophic  variety  demonstrated  by  staining 
or  inoculation— Tuberculosis  of  the  vagina ;  ulcerative  form  most  frequent  variety 
—Histologic  examination— Hypertrophic  form  in  relation  to  miliary  tuberculosis 
— Tuberculosis  of  the  cervix,  ulcerative,  papillary,  miliary,  and  interstitial — His- 
tologic examination— Characteristics,  and  differentiation— Corporeal  endometritis; 
miliary  and  caseous — Study  of  histologic  and  pathologic  characteristics — Myome- 
tritis, frequent  occurrence  in  advanced  cases  of  tuberculous  endometritis — In- 
fections of  the  endometrium — Intramural  abscess,  tuberculous  deciduitis — His- 
tologic examination — Placental  tuberculosis — Macroscopic  appearance,  character- 
istics and  forms — Intravillous  tuberculosis — Intravascular  chorionic  lesions,  and 
chorio-amniotic — Tuberculosis  of  fallopian  tubes — Tuberculosis  of  the  ovary — 
Peri-oophoritis,  and  oophoritis — Histologic  examination. 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA 

As  has  been  stated  elsewhere,  tuberculosis  of  the  external  genitalia 
may  be  either  primary  or  secondary,  the  latter  being  by  far  the  most  fre- 
quent. As  the  vulva  and  adjacent  structures  are  covered  by  modified 
skin,  tuberculosis  occurring  in  this  locality  is  similar  in  its  general 
macroscopic  and  histologic  characteristics  to  tuberculosis  of  the  cutane- 
ous surface  as  found  in  other  parts  of  the  body.  As  a  result,  however, 
of  moisture,  heat,  friction,  and  local  anatomic  conditions,  and  not  infre- 
quently due  to  the  presence  of  irritating  discharges,  certain  modifica- 
tions of  the  ordinary  tuberculous  lesions  found  in  other  skin  areas  may 
occur.  As  a  general  rule,  the  pathologic  processes  which  occur  here 
closely  resemble  the  ordinary  forms  of  cutaneous  tuberculosis. 

Undoubtedly  the  rarity  of  tuberculosis  of  the  external  genitalia  may 
be  largely  explained  by  the  protective  qualities  of  the  squamous  epithe- 
lium and  particularly  of  the  horny  layer  of  the  latter.  In  young  chil- 
dren the  development  of  the  outer  horny  layer  is  less  marked  and,  as  a 
result,  in  such  subjects  this  locality  is  less  immune.  In  the  adult  con- 
stant bathing  of  the  parts  in  leukorrheal  discharges,  which  more  or  less 
macerates  the  protective  covering,  probably  acts  as  a  predisposing  factor 
to  infection.     The  irritating  properties  of  the   discharge  likely  to  be 

15 


16  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

present  as  a  result  of  lesions  in  the  upper  genital  tract  are  also  predis- 
posing causes  by  producing  a  vulvitis,  which  is  due  to  toxins.  Experi- 
mental studies  have  amply  proven  the  relationship  existing  between  pre- 
existing inflammation  and  infection  with  the  tubercle  bacillus  in  this 
locality. 

Tuberculosis  of  the  external  genitalia  may  be  divided  into  two  dis- 
tinct forms,  the  ulcerative  and  the  hypertrophic,  the  former  being  much 
the  most  common.  Combinations  of  the  two  are,  however,  not  infre- 
quent. 

Ulcerative  Form. — The  lesions  may  be  single  or  multiple  and  vary 
in  size  from  the  microscopic  to  huge  ulcers,  involving  not  only  the  ex- 
ternal genitalia,  but  also  the  skin  perineum,  vagina,  and  adjacent  struc- 
tures. Vulvovaginal  ulcers  are  relatively  frequent  and  may  originate 
either  in  the  vagina  or  vulva.  The  clitoris  and  surrounding  parts  are 
frequently  involved.  Ulcers  may  occur  either  on  the  labia  major  or 
minor,  or  both  may  be  attacked.  Contact  ulcers  on  the  opposite  labium 
occasionally  are  present.  Fistulae  leading  to  tuberculous  foci  in  the 
lower  alimentary  tract,  near-by  osseous  system,  or  other  localities  may 
be  present. 

The  vulvar  surface  adjacent  to  the  ulcer  is  generally  the  seat  of  a 
more  or  less  well  marked  chronic  inflammation,  the  skin  being  red- 
dened and  swollen.     Pigmentation  is  often  present. 

The  initial  genital  lesion  is  usually  a  small  swelling,  papule-like  in 
character,  which  enlarges,  softens  and  breaks  down,  leaving  in  its  center 
an  irregular  necrotic  ulcer.  Less  frequently  the  primary  pathologic 
process  is  a  minute  shallow  ulcer.  In  either  event,  the  subsequent  course 
is  usually  slow,  but  progressive,  and  more  or  less  swelling  and  hyper- 
trophy are  likely  to  occur.  The  base  of  the  ulcer  is  usually  dark  necrotic, 
but  may  be  reddish,  pinkish,  or  grayish  in  color.  Small  yellowish  or 
grayish  elevations  are  not  infrequently  present,  while  in  some  instances 
more  or  less  typical  tubercles  may  be  observed.  These  are  minute,  gray- 
ish or  yellowish,  semitranslucid  homogeneous  elevations,  and  are  gen- 
erally observed  on  the  floor  of  the  ulcer.  To  the  touch  the  base  of  the 
ulcer  imparts  a  soft,  somewhat  velvety  feel.  The  walls  of  the  lesion 
are  elevated,  infiltrated,  somewhat  edematous  and  often  undermined,  and 
may  be  the  seat  of  enlarged  veins.  In  some  instances  the  ulcers  are 
friable  and  tend  to  bleed  easily  when  traumatized.  The  older  lesions  are 
generally  fairly  firm  and  exhibit  but  little  tendency  to  hemorrhage. 
One  of  the  chief  characteristics  of  the  ulcers  is  their  chronic  appearance. 
Not  infrequently,  in  old  chronic  cases,  the  ulcers  are  to  a  certain  extent 
serpiginous  and  leave  behind  scar  tissue  as  they  advance  in  other  di- 


PATHOLOGY  17 

rections.  More  or  less  eczema  and  swelling  are  usually  present  in  the 
neighborhood  of  the  ulcer.  In  some  instances,  where  the  ulcer  is  lim- 
ited to  one  side,  the  opposite  vulva  is  enlarged  or  hypertrophied.  En- 
larged or  varicose  veins  are  frequently  present,  especially  in  aged  patients. 
An  inguinal  adenitis  is  a  frequent  accompaniment  of  the  condition. 

On  histologic  examination,  the  ulcers  present  the  usual  characteristics 
of  skin  tuberculosis.  The  tissue  is  infiltrated  with  chronic  inflammatory 
products,  the  blood  vessels  are  enlarged  and  thrombi  may  be  present. 
The  surface  may  present  characteristic  caseous  structures,  and  typical 
tuberculous  giant  cells  are  nearly  always  present.  The  latter,  together 
with  the  tubercles,  are  the  chief  diagnostic  features.  Tubercle  bacilli  are 
present,  but  are  frequently  difficult  to  demonstrate  by  staining  methods. 
They  are  often  few  in  number,  but  can  be  discovered  if  a  careful  search 
is  made.  In  some  instances  the  organisms  can  be  demonstrated  in  the 
discharge  from  the  ulcer ;  in  this,  however,  they  are  generally  sparsely 
distributed,  and  consequently  difficult  to  find.  Furthermore,  the  dangers 
of  contamination  from  tubercle  bacilli  bearing  discharges  from  other 
lesions  must  be  borne  in  mind.  For  these  reasons  the  examination  of  the 
discharges  is  generally  unsatisfactory,  and  a  better  method  is  to  care- 
fully cleanse  the  surface  of  the  lesion,  lightly  curette  it  and  examine  the 
material  thus  obtained.  In  cases  of  doubt  biopsy  combined  with  animal 
inoculation  offers  the  surest  and  most  satisfactory  means  of  diagnosis. 

Hypertrophic  Variety. — In  this  variety  of  tuberculosis  the  infec- 
tion usually  results  in  moderate  sized  tumor-like  masses,  the  labia  being 
perhaps  the  most  frequent  area  involved.  The  lesions  are  generally 
fairly  firm,  somewhat  rounded  outgrowths,  often  covered  by  thickened 
wrinkled  skin.  Cases  have  been  mistaken  for  sarcoma,  carcinoma,  con- 
dyloma acuminata,  and  true  elephantiasis.  One  or  both  labia  may  be 
attacked,  but  a  unilateral  involvement  is  the  most  frequent.  More  or 
less  edema  and  swelling  of  the  opposite  side  and  adjacent  structures  is, 
however,  the  rule  in  advanced  cases.  Engorged  blood  vessels  are  some- 
times observed.  As  will  be  noted,  the  macroscopic  appearance  of  this 
form  of  tuberculosis  presents  nothing  characteristic. 

On  histologic  examination,  the  skin  is  usually  found  to  be  thickened, 
the  affected  area  fairly  vascular,  and  a  well  marked  increase  of  connec- 
tive tissue  is  everywhere  observed.  A  considerable  infiltration  with  a 
chronic  inflammatory  exudate  is  present,  although  this  is  less  marked 
than  is  observed  in  the  ulcerative  lesion.  Here  and  there  tubercles  con- 
taining the  characteristic  giant  cells  may  be  seen.  These,  however,  are 
not  plentiful,  and  a  number  of  sections  should  be  examined  in  suspected 
cases  before  the  possibility  of  tuberculosis  is  excluded.     Tubercle  bacilli 


18    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

are  generally  present  only  in  small  numbers  and  are  therefore  usually 
difficult  to  demonstrate  in  stained  sections. 

On  account  of  the  confusion  which  has  existed  in  the  past  regarding 
this  variety  of  tuberculosis,  the  author  believes  that  no  case  should  be 
classified  as  tuberculosis  unless  the  characteristic  lesions,  tubercles  and 
giant  cells  are  observed,  or  tubercle  bacilli  demonstrated  either  by  stain- 
ing or  inoculation  methods.  The  latter  is  the  best  and  most  certain  pro- 
cedure. 

TUBERCULOSIS  OF  THE  VAGINA 

Tuberculosis  of  the  vagina  is  similar  in  its  general  pathologic  char- 
acteristics to  tuberculosis  of  the  external  genitalia.  It  is  usually  of  the 
secondary  variety  and  may  result  from  a  direct  extension  from  nearby 
foci,  such  as  the  cervix  or  intestines,  or  from  a  hemogenic  or  lympho- 
genic infection.  Direct  implantation,  either  from  exogenic  organisms 
by  means  of  the  fingers,  douche  nozzle,  or  coitus,  or  by  tubercle 
bacilli  bearing  discharges  originating  in  the  upper  genital  tract,  may 
occur. 

Three  varieties  have  been  observed,  the  ulcerative,  the  hypertrophic 
and  the  miliary. 

The  Ulcerative  Form. — This  is  the  most  frequent  variety,  and  in 
general  presents  the  same  characteristics  as  when  present  on  the  external 
genitalia.     Indeed  vulvovaginal  lesions  are  relatively  frequent. 

The  ulcers  may  be  single  or  multiple  and  are  perhaps  most  frequently 
present  in  the  floor  of  the  vagina.  The  lesions  vary  considerably  in  size; 
huge  ulcers  involving  almost  the  entire  vagina  and  extending  to  the  ex- 
ternal genitalia  and  adjacent  structures  have  been  observed,  and  on  the 
other  hand,  almost  microscopic  lesions  have  been  recorded.  The  ulcers 
generally  present  a  chronic  appearance  and  possess  infiltrated,  elevated 
hyperemic  and  particularly  undermined  edges.  The  base  is  necrotic, 
brownish,  blackish,  pinkish,  or  grayish  in  color,  moderately  soft  and 
friable  to  the  touch,  and  is  frequently  studded  with  minute  rounded 
grayish  or  yellowish  semitranslucent  elevations,  which  histologic  exam- 
ination shows  to  be  tubercles.  The  surrounding  vaginal  mucosa  is  gen- 
erally reddened  and  presents  the  usual  appearance  of  a  vaginitis.  In  the 
early  stages  the  ulcers  are  shallow. 

The  lesions  are  to  be  differentiated  from  malignant  neoplasm,  syphilis, 
chancroids,  and  in  children  from  gonorrhea,  noma  of  the  vulva,  and  other 
ulcerative  lesions. 

The  presence  of  tuberculosis  elsewhere  in  the  body,  the  chronic  char- 


PATHOLOGY 


19 


acter  of  the  lesions,  and  the  presence  of  tubercle-like  elevations  on  the 
base  of  the  ulcer  are  points  suggestive  of  this  variety. 

On  histologic  examination,  any  doubts  which  may  exist  are  easily 
cleared  up.  The  vaginal  mucosa  surrounding  the  ulcer  is  thickened; 
hyperemic,  and  more  or  less  infiltrated  with  chronic  inflammatory  prod- 
ucts, and  may  contain  an  isolated  tubercle.  Sections  through  the  ulcers 
show  the  absence  of  the  normal  superficial  tissues,  the  floor  of  the  ulcer 
being  densely  infiltrated  with  a  chronic  inflammatory  exudate,  and  the 
surface  consisting  of  necrotic  granulation  tissue.  The  presence  of 
tubercles  and  the  characteristic  giant  cells  makes  the  diagnosis  positive. 
Tubercle  bacilli  can  generally  be  demonstrated  in  stained  sections,  if  care- 
ful search  for  them  is  instigated. 

Hypertrophic  Form. — Cases  of  this  kind  in  which  the  lesions  have 
originated  in  the  vagina  itself  are  too  few  to  draw  from  them  definite 
conclusions  regarding  their  characteristic  appearance.  By  far  the  greater 
number  of  cases  in  which  the  hypertrophic  form  of  tuberculosis  has  been 
present  have  resulted  from  a  direct  extension  from  a  similar  outgrowth 
in  the  cervix.  The  hypertrophic  variety  of  tuberculosis  is  usually  papil- 
lary in  appearance,  and  more  or  less  friable  and  necrotic.  The  tumor- 
like masses  are  bathed  in  an  irritating,  foul  smelling  discharge.  The 
outgrowths  are  pinkish  or  grayish  in  color  and  frequently  present  ex- 
tensive areas  of  necrosis.  In  the  interstices  on  the  surface  collections 
of  clotted  blood  and  discharge  are  frequently  present. 

Histologically,  the  lesions  present  the  usual  characteristics  of  tuber- 
culosis, although  tubercles  are  less  plentiful  than  in  the  former  variety. 
In  some  specimens  there  is  marked  increase  in  the  number  of  blood  ves- 
sels, and  a  correlation  with  the  macroscopic  and  clinical  findings  will 
usually  show  that  these  specimens  are  more  friable,  rapid  in  growth, 
and  productive  of  more  easily  excited  small  hemorrhages,  especially  fol- 
lowing trauma,  than  in  the  less  vascular  pathologic  processes.  Tubercle 
bacilli  are  present,  but  as  a  rule  less  numerously  than  in  the  ulcerative 
variety. 

Miliary  Tuberculosis. — In  this  variety  of  the  disease,  the  vaginal 
mucosa  is  thickened,  reddened,  swollen,  more  or  less  edematous,  and 
hyperemic.  The  entire  vaginal  lining  is  usually  involved,  although  the 
inflammation  is  apt  to  be  most  marked  in  the  floor  of  the  canal.  Scat- 
tered more  or  less  profusely  throughout  the  lining  of  the  vagina  are  small 
grayish  or  yellowish  semitranslucent  discrete  elevations — the  tubercles. 
Occasionally  one  of  these  breaks  down  and  a  small  ulcer  results.  Con- 
siderable discharge  is  usually  present. 

Histologic  examination  shows  a  well  marked  inflammation  and  the 


20         GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

usual  characteristics  of  tuberculosis.  Tuberculous  giant  cells  and  tuber- 
cle bacilli  are  generally  present  in  considerable  numbers.  This  variety 
of  the  disease  is  generally  the  result  of  a  hemogenic  infection,  and  is 
usually  associated  with  a  general  miliary  infection. 

Combinations  of  the  ulcerative,  hypertrophic,  and  miliary  forms  may 
be  present. 

TUBERCULOSIS  OF  THE  CERVIX 

Cervical  tuberculosis  occurs  in  four  distinct  forms :  the  ulcerative, 
the  papillary,  the  miliary,  and  interstitial.  An  analysis  of  106  cases 
showed  that  52  were  of  the  ulcerative  variety,  41  papillary,  7  miliary,  and 
6  interstitial.  Combinations  of  these  varieties  are  not  infrequent.  These 
statistics  may  to  some  extent  be  misleading,  owing  to  the  fact  that  in 
the  late  stages,  when  many  of  these  cases  were  first  observed,  ulcerative 
lesions  are  prone  to  develop.  Thus,  a  lesion  which  began  as  an  inter- 
stitial type  in  the  later  stage  may  break  through  into  the  portio  or  cervical 
canal  and  present  a  condition  which  would  probably  be  classified  under 
the  ulcerative  variety.  Cora  x  believes  the  papillary  variety  the  most  fre- 
quent, and  bases  this  opinion  upon  the  fact  that,  in  the  later  stages,  this 
variety  frequently  undergoes  ulcerative  changes. 

Cervical  tuberculosis  is  usually  secondary;  a  few  authentic  primary 
cases  have,  however,  been  recorded.  Beyea  2  analyzed  61  cases,  with  a 
view  to  ascertaining  what  portion  of  the  cervix  was  most  frequently 
attacked.  In  this  series  the  portio  alone  was  involved  in  11,  the  supra- 
vaginal cervix  alone  in  6,  and  both  in  44.  The  disease  usually  originates 
in  the  cervical  canal. 

Ulcerative  Variety. — Cervices,  the  seat  of  this  variety  of  tubercu- 
losis, vary  widely  in  appearance.  All  of  the  four  varieties  of  cervical 
tuberculosis  are  prone  to  become  ulcerative  in  their  end  stages.  As  a 
general  rule,  the  pathologic  process  produced  by  the  ulcerative  variety 
of  cervical  tuberculosis  resembles  more  or  less  closely  the  ulcerative  ten- 
sions of  carcinoma.  Indeed,  malignancy  of  some  form  has  been  the 
clinical  diagnosis  in  a  large  proportion  of  cases,  not  only  in  the  ulcera- 
tive variety,  but  also  in  the  papillary  forms.  The  ulcer  may  begin  either 
in  the  portio  vaginalis  or  in  the  cervical  canal.  The  history  usually  shows 
that  the  disease  has  been  slow,  but  progressive.  The  margins  of  the 
ulcers  are  often  not  markedly  elevated,  less  so  as  a  rule  than  in  carci- 
noma, and  are  apt  to  be  undermined  and  fairly  soft.  The  base  is  covered 
with  necrotic  tissue  and  may  be  brown,  black,  yellow  or  gray  in  color.  It 
is  usually  moderately  soft  and  friable,  but  in  some  specimens  is  firm  and 


PATHOLOGY  21 

hard.  Numerous  minute  grayish  or  yellowish  semitranslucent  discrete 
tubercles  may  be  scattered  over  the  floor  of  the  ulcer.  These  may  also  be 
present  in  the  walls  of  the  ulcer  and  on  the  surface  of  the  adjacent 
structures,  Not  infrequently  the  surface  of  the  ulcer  will  be  found  to 
be  partially  covered  by  cheesy  particles.  The  ulcers  are  usually  single, 
but  multiple  lesions  have  been  observed.  The  ulcers  vary  widely  in  size ; 
in  some  specimens  the  place  of  the  entire  cervix  and  adjacent  vagina  is 
occupied  by  a  large  excavated  necrotic  cavity,  while  in  others  almost 
microscopic  lesions  have  been  described.  In  the  advanced  specimens  inr 
volvement  of  the  surrounding  vagina  is  frequent.  The  adjacent  covering 
of  the  vagina  and  the  portion  of  the  cervix  not  actually  involved  by  the 
ulcers  are  usually  reddened,  and  as  has  been  stated,  may  contain  small 
tubercles.  The  ulcers  may  extend  upward  into  the  body  of  the  uterus, 
but  the  disease  apparently  exhibits  some  tendency  toward  remaining 
limited  to  the  area  below  the  internal  os,  although  a  tuberculous  endo- 
metritis is  frequently  present. 

Papillary  Variety. — This  variety  usually  originates  from  the 
vaginal  surface  of  the  cervix,  but  in  rare  instances  may  spring  from  the 
canal.  It  occurs  usually  as  a  cauliflower-like  outgrowth,  and  is  generally 
dark  reddish  or  brownish  in  color,  presents  necrotic  areas  on  its  sur- 
face, and  is  covered  with  discharge.  Firm  smooth  nodular  dome-like 
elevations  may  be  present,  either  in  conjunction  with  the  cauliflower 
type  of  tumor,  or  less  frequently  may  constitute  the  chief  patho- 
logic process  present.  On  section,  the  papillary  variety  of  tuber- 
culosis presents  a  smooth,  fairly  soft,  somewhat  translucent,  mod- 
erate vascular  pinkish,  grayish  or  whitish  appearance;  small  yellowish 
areas  on  the  cut  surface  may  be  observed  in  some  specimens.  The 
tumor-like  outgrowth  may  possess  a  well  defined  pedicle,  but  more  fre- 
quently springs  from  a  broad  base.  In  the  early  stage  this  variety  is 
usually  single,  but  later  numerous  outgrowths  are  observed.  As  the  dis- 
ease progresses  the  tumor-like  masses  tend  to  undergo  necrosis  and  ul- 
ceration. 

Interstitial  Variety. — In  this  variety  the  disease  begins  in  the  sub- 
stance of  the  cervix,  primarily  causing  a  slight  nodular  swelling  in  one 
lip  of  the  organ ;  this  gradually  increases  in  size  and  finally  breaks  down, 
leaving  an  irregular  opening  either  on  the  portio  or  in  the  canal.  The 
opening  becomes  larger  as  the  result  of  a  disintegration  of  tissues,  and 
the  final  stage  is  a  large  crater-like  cavity,  together  with  involvement 
of  much  of  the  adjacent  tissue.  The  walls  of  the  cavity  are  similar  in 
general  macroscopic  appearance  to  those  of  the  ulcerative  variety  of 
the  disease. 


22         GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Miliary  Variety. — In  this  variety  the  cervix  is  usually  enlarged, 
the  portio  reddened  and  glistening,  and  scattered  discretely  over  the 
surface  are  small  grayish  or  yellowish  semitranslucent  elevations,  which 
are  the  tubercles.  These  may  be  seen  in  various  stages  of  development. 
Not  infrequently  one  of  these  may  break  down,  leaving  a  minute  ulcer 
filled  with  whitish  or  yellowish  cheesy  material.  The  mucosa  of  the 
cervical  canal  is  usually  the  seat  of  a  tuberculous  endocervicitis.  The 
vagina  may  also  be  involved.  The  specimen  is  likely  to  be  bathed  in  a 
moderate  thin  semipurulent  discharge,  intermixed  with  which  cheesy 
particles  may  be  present. 

As  a  result  of  tuberculosis  of  the  cervix,  the  canal  may  become 
occluded  and  a  pyometra  or,  as  it  is  sometimes  termed,  uterine  phthisis 
may  result.  When  this  occurs  the  uterus  becomes  larger  and  softer, 
and  the  amount  of  leukorrhea  is  likely  to  become  somewhat  lessened  as 
the  discharge  from  the  upper  genital  tract  ceases  to  gain  egress.  Pyo- 
metra is  most  frequent  in  the  ulcerative  and  papillary  forms. 

Occasionally  specimens  are  observed  in  which  there  is  marked  re- 
duplication of  the  columnar  epithelium  and  a  tendency  towards  a  con- 
centric arrangement  of  the  cells,  which  somewhat  resembles  carcinoma. 
A  similar  arrangement  of  the  squamous  epithelium  has  been  described, 
in  which  groups  of  cells  are  present  which  somewhat  suggest  cancer 
pearls.  By  a  careful  histologic  examination  the  differentiations  of  these 
two  conditions  is  always  rendered  feasible.  The  mitosis,  hyperchroma- 
tosis,  rapid  proliferation,  and  penetrating  character  of  the  cancer  cells 
and  the  absence  of  tubercles  should  make  the  differentiation  possible  in 
all  cases. 

Tubercle  bacilli  can  frequently  be  demonstrated  in  smear  specimens 
and  almost  always  by  animal  inoculation,  although  in  old  cases  mixed 
infections  are  of  frequent  occurrence  and  at  times  make  the  demonstra- 
tion of  the  original  type  of  infection  difficult.  As  a  result  of  the 
amenorrhea  and  uterine  enlargement  which  results,  cases  in  which  a 
pyometra  has  been  present  have  been  mistaken  for  pregnancy.  It  is 
needless  to  state  that  a  properly  conducted  examination  should  easily 
clear  up  such  an  erroneous  diagnosis.  The  pus  in  the  uterine  cavity 
is  usually  yellowish  and  creamy  in  consistency  and  not  infrequently 
contains  cheesy  particles  and  possesses  a  foul  odor. 

Histologic  Examination. — However  difficult  the  clinical  diagnosis 
may  be  in  these  cases,  the  histologic  diagnosis  is  usually  easy.  The 
well  marked  evidence  of  chronic  inflammation,  the  necrosis,  and  lastly 
the  characteristic  tubercles  and  the  frequent  presence  of  tuberculous 
giant  cells,  clear  up  any  doubts  which  may  have  existed.     Histologically 


PATHOLOGY 


23 


the  inflammatory  exudate  is  characterized  by  the  presence  of  small 
round  cells  and  a  few  polymorphous  leukocytes.  In  the  ulcerative  va- 
riety the  inflammation  is  most  marked  at  the  edge  of  the  lesion.  In 
addition,  there  is  loss  of  surface  epithelium  and  of  underlying  tissue, 
the  erosion  being  lined  by  necrotic  material.  The  cervical  glands  in 
some  areas  may  be  destroyed  or  unrecognizable.  The  blood  vessels  are 
engorged.  In  the  papillary  type,  polypoid  or  papilla-like  projections 
are  present,  which  are  covered  by  squamous  or  cylindrical  epithelium, 
according  to  their  point  of  origin.  In  either  event,  the  surface  epithe- 
lium is  prone  to  proliferation,  although  the  individual  cells  may  be  more 
or  less  normal.  The  stroma  of  the  outgrowths  is  composed  of  cervical 
tissue,  and  is  usually  infiltrated  with  chronic  inflammatory  products. 
Tubercles  and  giant  cells  in  varying  numbers  are  present. 

Tubercle  bacilli  may  be  demonstrated  in  stained  preparations  in 
most  cases,  if  a  careful  search  is  instigated.  In  some  instances,  how- 
ever, they  are  few  in  number,  and  in  these  cases  animal  inoculation 
offers  a  means  of  positive  diagnosis  and  should  be  employed  in  all 
cases  in  which  doubt  exists. 


CORPOREAL  ENDOMETRITIS 

With  the  exception  of  the  fallopian  tube,  the  endometrium  of  the 
body  of  the  uterus  is  the  structure  most  frequently  involved  in  tuber- 
culous infection  of  the  female  genital  tract.  Careful  study  has  shown 
that  tuberculous  endometritis  is,  like  a  similar  infection  of  the  tubes, 
much  more  frequent  than  was  formerly  thought  before  routine  histo- 
logic examination  of  tissues  removed  at  operations  was  generally  prac- 
ticed. Mayo  3  states  that  tuberculous  endometritis  in  the  menstruating 
uterus  is  infrequent.  This  has  not  been  our  experience;  nearly  80 
per  cent  of  our  cases  have  occurred  during  active  sexual  age. 

The  disease  exists  in  two  well  defined  varieties — (1)  the  miliary 
and  the  (2)  caseous  or  ulcerative. 

The  Miliary  Variety. —  In  many  specimens,  at  the  seat  of  this 
variety  of  tuberculosis  the  macroscopic  lesions  are  not  marked  and  un- 
less a  histologic  examination  is  performed,  no  suspicion  of  the  presence 
of  this  type  of  infection  may  be  aroused.  The  entire  endometrium  is 
by  no  means  always  involved.  The  infection  may  be  blood  borne,  the 
primary  and  perhaps  only  genital  lesion  being  in  the  endometrium;  or 
the  endometritis  may  be  secondary  to  a  salpingitis,  either  as  a  result  of 
a  direct  infection  by  continuity  from  the  tubal  mucosa,  or  by  contamina- 


24    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

tion  due  to  leakage  of  the  tubal  contents  through  the  uterine  ostia  of  the 
tube.  It  is  often  difficult  to  determine  which  of  these  routes  infection 
has  followed.  The  tubes  are  generally  involved.  Endometritis,  the  di- 
rect result  of  a  bacteriemia,  is  more  frequent  in  the  miliary  variety  than 
in  the  caseous,  which  latter  is  nearly  always  secondary  to  tubal  lesions. 

In  advanced  cases,  the  mucosa  is  reddened  and  thickened  and  hyper- 
emic;  the  superficial  tissue  may  contain  small  discrete  yellowish  or 
grayish  semitranslucent  elevations,  which  are  tubercles.  In  some  speci- 
mens the  tubercles  can  be  plainly  discerned  with  the  naked  eye,  while  in 
others  they  are  less  conspicuous,  and  their  presence  may  not  be  suspected 
until  a  histologic  examination  is  made.  The  uterus  is  usually  slightly 
enlarged  and  not  infrequently  tubercles  can  be  seen  upon  the  peritoneal 
surface.  This  is  especially  likely  to  be  the  case,  if  a  tuberculous  peri- 
tonitis has  been  present.  An  accompanying  salpingitis  is  the  rule.  In 
rare  instances,  as  a  result  of  adhesions  at  the  internal  os,  occlusion  of 
the  canal  occurs  and  results  in  a  pyometra.  The  pus  under  such  cir- 
cumstances is  usually  thick,  creamy  and  yellowish  in  color,  and  may 
contain  cheesy  particles.  Pyometra  is  rare,  unless  definite  cervical  le- 
sions are  present. 

Histologic  Examination. — This  presents  a  somewhat  varying 
picture.  In  some  specimens  the  infection  is  chiefly  superficial,  the 
deeper  portions  of  the  endometrium  being  comparatively  normal.  In 
its  very  early  stages,  tuberculous  endometritis  cannot  be  distinguished 
from  other  forms  of  inflammation  (Schramm4).  The  inflammation 
begins  upon  the  surface  in  the  majority  of  cases  (Orthman  and  Mun- 
son,5  Rosenstein6).  This  type  of  infection  is  usually  acute,  although 
specimens  in  the  chronic  stage  are  encountered.  The  mucosa,  besides 
being  thickened,  is  infiltrated  with  inflammatory  products  and  contains 
more  or  less  numerous  tubercles,  in  many  of  which  typical  giant  cells 
are  present.  Tubercles  may  generally  be  observed  in  varying  stages  of 
development,  and  are  always  insterstitial  in  location.  A  more  or  less 
superficial  involvement  of  the  underlying  myometrium  is  usually  pres- 
ent, and  in  some  uteri  may  be  a  marked  feature  of  the  specimen.  The 
blood  vessels  of  the  mucosa  are  usually  enlarged  and  the  infection  tends 
to  spread  along  them  and  the  lymphatic  channels.  Tubercle  bacilli  can 
frequently  be  demonstrated  in  stained  sections  in  the  tubercles,  espe- 
cially if  the  lesions  are  in  the  acute  stage. 

Caseous  Variety. — In  the  caseous,  or  as  it  is  sometimes  spoken  of, 
the  cheesy  or  infiltrating  variety,  the  macroscopic  evidences  of  the  dis- 
ease are  more  marked  and  more  characteristic.  The  uterus  is  usually 
somewhat  enlarged,  the  tubes  are  likely  to  be  involved,  and  tubercles 


PATHOLOGY  25 

may  be  present  upon  the  peritoneal  surface.  Although  tubercles  upon 
the  peritoneum  are  of  frequent  occurrence,  they  are  perhaps  less  often 
observed  than  in  the  miliary  variety.  Upon  opening  the  uterus,  the 
myometrium  is  often  somewhat  thickened  and  presents  evidence  of  a 
chronic  inflammation.  The  entire  endometrial  cavity  may  be  filled 
with  yellowish  or  whitish  cheesy  material,  or  part  of  the  mucosa  may 
be  thickened  and  reddened  and  perhaps  contain  macroscopic  tubercles, 
and  other  areas  may  be  covered  with  caseous  material.  Tuberculous 
endometritis  does  not  occur  with  uniform  severity  over  the  entire  cor- 
poreal endometrium,  but  patches  of  disease  are  likely  to  be  present, 
especially  in  those  areas  near  the  tubal  ostia,  and  in  all  specimens  in 
this  location  the  lesions  are  prone  to  be  the  most  advanced.  Some  areas 
are  likely  to  be  the  seat  of  an  advanced  change,  and  others  may  con- 
tinue comparatively  normal.  This  characteristic  is  common  to  all  forms 
of  endometritis,  whether  tuberculous  or  otherwise,  and  has  been  empha- 
sized by  Hitschmann  and  Adler,7  by  Strong,8  and  by  other  observers. 
During  the  late  stages  of  the  disease,  however,  the  entire  endometrial 
cavity  is,  as  a  rule,  involved.  The  superficial  and  even  the  deeper  lay- 
ers of  the  endometrium  become  necrotic,  the  endometrium  is  destroyed, 
and  a  marked  involvement  of  the  myometrium  occurs.  As  a  result  of 
the  destruction  of  the  endometrium,  amenorrhea  is  likely  to  result,  and, 
viewed  in  conjunction  with  the  uterine  enlargement,  has  led  to  a  mis- 
taken diagnosis  of  pregnancy.  One  or  more  ulcers  may  be  present; 
these  are  lined  by  necrotic  tissue  and  often  partially  or  entirely  covered 
with  cheesy  material. 

As  a  rule,  in  both  this  and  the  miliary  variety  of  the  disease,  a 
tendency  exists  for  the  condition  to  limit  itself  to  areas  above  the  in- 
ternal os,  and  in  some  of  the  specimens  of  the  cheesy  variety  of  infection, 
this  characteristic  is  most  striking.  Only  in  comparatively  rare  in- 
stances is  the  cervix  invaded. 

Histologic. — The  histologic  picture  depends  largely  upon  the  stage 
of  the  disease.  This  variety  is  more  prone  to  exhibit  chronic  changes 
than  is  the  miliary  form.  The  pathologic  process  may  vary  from  a 
partial  involvement  of  some  portion  of  the  mucosa  to  a  total  destruction 
of  the  entire  mucosa,  and  more  or  less  of  the  underlying  myometrium. 
The  surface  is,  as  a  rule,  necrotic,  and  the  deeper  portions  of  the  mucosa 
exhibit  the  changes  common  to  a  chronic  inflammation.  In  tuberculous 
endometritis  the  chief  changes  are  in  the  interstitial  portions  of  the 
mucosa.  The  glandular  epithelium  apparently  possesses  a  partial  im- 
munity. In  some  specimens  observed  by  the  author,  a  well  marked 
proportion  of  the  glandular  epithelium  has  been  present,   and  even  a 


26  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

tendency  toward  a  squamous  metaplasia  has  been  observed.  The 
epithelium,  as  a  rule,  although  exhibiting  the  above  mentioned  tendency 
to  withstand  desquamation,  by  no  means  escapes  inflammatory  reactions, 
and  in  many  instances  the  cells  are  enlarged,  swollen,  irregular  in  shape, 
lose  their  cilia,  and  exhibit  well  marked  nuclear  changes;  the  nuclei 
often  are  enlarged,  nearly  filling  the  cell,  and  stain  irregularly,  fre- 
quently deeply,  and  may  possess  well  marked  hyperchromatic  qualities. 
The  surface  epithelium  is  lost  before  that  of  the  glands,  and  in  chronic 
cases  may  be  replaced  by  granulation  tissue.  The  distinguishing  histo- 
logic characteristics  of  this,  as  of  all  tuberculous  changes,  is  the  tubercle. 
These  are  interstitial  in  location,  show  the  usual  epithelioid  appearance 
and  frequently  contain  tuberculous  giant  cells.  These  possess  large  dis- 
tinct nuclei,  which  are  often  distributed  with  a  certain  regularity.  The 
tubercles  and  inflammatory  changes  are  by  no  means  limited  to  the 
mucosa,  the  underlying  musculature  usually  being  more  or  less  invaded. 
Indeed,  in  advanced  cases  no  trace  of  the  mucosa  may  remain,  the 
surface  being  covered  with  a  layer  of  necrotic  tissue,  beneath  which 
is  a  zone  of  degenerating  and  inflammatory  granulation  tissue,  and 
finally  the  inflamed  myometrium.  In  still  other  specimens,  necrotic 
myometrium  actually  lines  the  endometrial  cavity. 

Tubercle  bacilli  can  generally  be  demonstrated  in  stained  sections, 
if  a  careful  search  is  instigated.  In  the  acute  stages,  tubercle  bacilli 
are  usually  present  in  considerable  numbers  and  little  difficulty  is 
encountered  in  their  demonstration.  In  chronic  cases,  the  demonstra- 
tion of  the  bacillus  by  staining  methods  alone  is  sometimes  difficult, 
as  the  organisms  are  comparatively  few  in  number  and  may  possess 
atypical  forms. 

Myometritis. — As  has  been  stated,  a  greater  or  less  involvement 
of  the  underlying  myometrium  is  of  frequent  occurrence  in  advanced 
cases  of  tuberculous  endometritis.  These  uteri  may  be  normal  or 
somewhat  enlarged.  Beyond  the  fact  that  a  salpingitis,  usually  bilateral, 
is  generally  present,  no  macroscopic  evidences  of  infection  are  neces- 
sarily present.  Adhesions  over  the  peritoneal  surface  may  be  observed, 
and  in  some  instances  the  serous  coat  is  studded  with  tubercles.  In  a 
large  proportion  of  specimens,  however,  nothing  strongly  suggestive 
of  the  variety  of  infection  can  be  observed. 

In  tuberculosis  perhaps  more  frequently  than  in  any  other  inflam- 
mation calcareous  deposits  may  be  formed.  These  may  occur  as  small 
flakes  or  as  well  defined  bone-like  particles.  In  some  instances,  as  a 
result  of  inflammatory  occlusion  at  the  cervico-uterine  junction,  a  pyo- 
metra  occurs.     In  this  case  the  body  of  the  uterus  is  more  or  less  sym- 


PATHOLOGY  27 

metrically  enlarged,  and  is  likely  to  feel  softer  and  suggest  an  ill  defined 
sense  of  fluctuation.  On  opening  the  uterine  cavity,  the  appearance  of 
the  endometrium  may  suggest  tuberculosis.  The  myometrium  is  often 
thickened,  and  may  be  the  seat  of  small  caseous  areas  discernible  to  the 
naked  eye. 

Histological  Examination. — Upon  histological  examination,  the 
endometrium  almost  invariably  presents  the  changes  previously  de- 
scribed. The  myometrium  presents  the  usual  evidence  of  inflammation 
either  of  the  acute  or  the  subacute  or  chronic  type.  In  addition,  how- 
ever, tubercles  are  found  scattered  throughout  the  tissue.  Many  of 
these  contain  the  typical  tuberculous  giant  cells.  As  has  been  previously 
stated,  the  inflammation  in  the  myometrium  tends  to  advance  along  the 
course  of  the  blood  or  lymph  spaces  or  between  the  interstices  of  the 
myometrium.  Actual  intramural  abscesses  are  occasionally  present,  but 
these  in  nearly  all  instances  communicate  with  the  endometrial  cavity. 
The  condition  is  nearly  always  secondary  to  endometritis,  and  as  a  re- 
sult the  inner  layers  of  the  myometrium  are  likely  to  be  chiefly  in- 
volved; in  old  chronic  cases,  however,  even  the  outermost  layer  of  the 
myometrium  may  be  invaded.  Tubercle  bacilli  are  present,  but  their 
demonstration  in  the  depths  of  the  muscle  is  as  a  rule  much  more  diffi- 
cult than  from  the  endometrium.  Small  cheesy  particles  should  be 
selected  for  smear  preparations,  and  in  stained  sections  tubercles  should 
be  examined. 

Intramural  Abscess. — Intramural  abscesses  may  be  small  or  large, 
and  single  or  multiple.  They  are  present  more  frequently  in  the  inner 
and  central  layers  of  the  myometrium  and  less  frequently  in  the  external 
layer.  As  a  general  rule,  the  abscesses  are  distinctly  secondary  to  in- 
fection of  the  endometrium.  The  pus  is  usually  thick  yellowish  and 
often  contains  degenerated  cheese-like  particles.  These  abscesses  are 
perhaps  most  frequent  in  the  fundus  of  the  uterus  in  the  neighborhood 
of  the  cornua. 

In  rare  instances,  tuberculous  abscesses  of  the  myometrium  have 
been  observed  in  conjunction  with  normal  endometrium.  In  1840 
Osiander  9  reported  a  case  in  which  there  were  nine  or  ten  soft  tumor-like 
masses  present  in  the  uterus.  These  were  thought  to  be  of  tuberculous 
origin.  In  view  of  the  ill  defined  knowledge  of  the  pathology  of  genital 
tuberculosis  at  that  period,  and  the  rather  meager  description,  this  case 
must  be  looked  upon  with  grave  suspicion. 

Madlener  10  has  reported  the  history  of  a  case  of  secondary  tuber- 
culous infection  of  an  adenomatous  polyp,  which  he  believes  resulted 
from  an  entirely  local  caseous  focus  in  the  myometrium.     Zahn  ll  has 


28    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

related  a  somewhat  similar  case  of  infection  of  a  polyp  from  a  tuber- 
culous ulcer  of  the  endometrium.  Wassmer 12  reports  from  Runge's 
clinic  in  Gottingen  six  cases  of  tuberculosis,  five  of  the  endometrium  and 
one  in  which  there  was  an  abscess  of  the  myometrium.  The  latter  case 
occurred  in  a  sterile  woman,  39  years  of  age.  Wassmer  states  his  be- 
lief that  in  this  case  the  infection  began  from  a  diffuse  tuberculous  peri- 
tonitis, and  from  thence  spread  to  the  uterine  musculature  and  later  to 
the  endometrium.  The  abscesses  were  moderately  large  and  tumor-like 
in  appearance.  Gottschalk  13  cites  a  case  occurring  in  a  virgin,  32  years 
of  age,  in  which  there  was  a  circumscribed  tuberculous  process  clearly 
intramuscular  in  location  and  separated  from  the  endometrial  cavity  by 
healthy  myometrium.  Tuberculous  adnexitis  was  present.  Gottschalk 
believes  this  proves  that  tuberculosis  can  localize  itself  in  the  uterine 
muscles  by  way  of  the  lymphatics.  Papow  14  cites  the  case  of  a  multi- 
para, 39  years  of  age,  who,  in  addition  to  cervical  and  adnexal  lesions, 
had  an  abscess  in  the  anterior  surface  of  the  uterus,  near  the  left  cornu. 
Frome  15  performed  a  vaginal  hysterectomy  upon  a  patient  41  years  of 
age  for  profuse  and  repeated  hemorrhages.  Bilateral  adnexitis  and 
macroscopic  tubercles  in  the  endometrium  were  present.  In  the  inner- 
most layer  of  the  myometrium  existed  numerous  tubercles.  An  intra- 
mural abscess  was  found.  Watkins  w  reported  the  history  of  a  case 
of  an  intramural  abscess  which  occurred  in  a  patient  43  years  of  age. 
The  family  history  Was  negative  for  tuberculosis,  and  she  was  sterile. 
Five  months  before  operation  the  patient  fell  and  sustained  an  injury 
to  the  left  side  of  the  abdomen,  low  down.  Pain  continued  for  months. 
The  patient  was  afebrile,  but  there  was  loss  of  weight  and  strength, 
and  upon  examination  the  condition  simulated  a  uterine  myoma.  The 
uterus  was  enlarged  to  twice  its  normal  size,  and  in  the  anterior  wall 
there  was  a  myoma-like  intramural  swelling.  The  adnexa  and  endo- 
metrium were  normal.  On  section,  the  uterine  lesion  was  found  to  be 
about  3  cm.  in  diameter,  and  was  yellowish  in  color,  friable,  moist  and 
caseous.  No  true  capsule  was  present.  The  uterine  focus  was  found 
to  consist  of  confluent  tubercles  exhibiting  the  typical  characteristics 
of  tuberculosis.  There  was  much  advanced  caseous  necrosis  and  many 
miliary  tubercles  were  scattered  throughout  the  myometrium.  No  tuber- 
cle bacilli  were  demonstrated  in  sections,  but  the  histologic  diagnosis 
was  confirmed  by  animal  inoculation.  The  case  was  probably  one  of 
hemogenous  infection;  the  primary  focus  was  not,  however,  discov- 
ered. Roberts  17  has  reported  an  interesting  case  of  diffuse  tuberculosis 
of  the  uterus  with  abscess  formation,  which  simulated  a  myoma.  The 
patient  was  49  years  of  age  and  single.     Some  time  previously  she  had 


PATPIOLOGY  29 

been  curetted  for  irregular  bleeding-.  The  curettings  were  not  histo- 
logically examined.  The  hemorrhages  recurred.  The  lungs  were  nor- 
mal. Operation  was  decided  upon.  No  tubercles  were  present  in  the 
peritoneum,  the  right  tube  had  been  converted  into  a  pyosalpinx  and  the 
left  into  a  hydrosalpinx.  The  uterus  was  irregularly  enlarged  and 
covered  with  adhesions.  The  uterine  walls  were  thickened,  and  contained 
numerous  areas  of  suppuration  from  which  cheesy  worm-like  bodies 
could  be  squeezed.  All  the  myometrium  was  more  or  less  involved,  but 
not  markedly  in  the  region  of  the  cornua.  The  endometrial  cavity  was 
enlarged,  the  walls  were  necrotic  and  contained  purulent  material.  Sec- 
tions showed  a  diffuse  tuberculosis,  as  instanced  by  numerous  areas  of 
caseous  degeneration  with  epithelioid  and  giant  cells.  Apparently  the 
same  case  has  also  been  reported  by  Stewart.18  Alessandrie  19  has  re- 
ported the  history  of  a  somewhat  similar  case. 

The  following  example  of  an  intramural  uterine  abscess  not  com- 
municating with  adnexa  or  endometrial  cavity  has  been  observed  by 
the  author:  Pathology,  No.  4108;  age  25  years;  shortly  after  marriage, 
four  years  ago,  a  profuse  purulent  leukorrhea  and  symptoms  of 
urethritis  appeared,  followed  by  a  labial  abscess.  One  child  three  years 
ago.  The  puerperium  was  complicated  by  pelvic  peritonitis.  Since 
then,  sterility  and  occasional  attacks  of  pelvic  peritonitis.  Examination 
on  admission  to  the  hospital  showed  a  small  tuberculous  lesion  at  the 
right  apex,  and  a  moderately  massive  pelvic  inflammatory  disease.  It 
was  the  latter  condition  that  brought  the  patient  to  the  hospital.  Gono- 
cocci  were  demonstrated  in  the  secretion  from  the  cervix  and  from  one 
of  Bartholin's  glands.  A  supravaginal  hysterectomy  and  bilateral  sal- 
pingo-oophorectomy  was  performed.  Convalescence  was  somewhat  pro- 
longed, but  otherwise  normal.  The  pathologic  examination  of  the  uterus 
and  appendages  showed  them  to  have  the  usual  appearances  of  pelvic 
inflammatory  disease.  The  tubes  were  converted  into  pyosalpinges. 
The  abdominal  ostia  were  closed  and  no  fimbria  could  be  distinguished, 
nor  were  there  any  tubercles  upon  the  peritoneal  surface.  One  ovary 
was  the  seat  of  a  small  abscess,  evidently  the  result  of  an  infection  of 
a  corpus  luteum;  the  other  was  enlarged,  covered  with  adhesions,  and 
contained  a  number  of  retention  cysts.  The  uterus  was  normal  in  size, 
and  in  the  left  cornu,  on  the  anterior  surface,  was  a  semifluctuant  swell- 
ing 2.5  x  2  x  1.5  cm.  Histologic  examination  showed  this  to  be  an 
intramural  abscess,  not  communicating  with  the  tube  or  endometrial  cav- 
ity. No  gonococci  were  demonstrated  in  either  of  the  adnexa  or  in  the 
intramural  abscess.  Numerous  tubercles,  many  of  which  contained 
typical  giant  cells,  were  present  in  the  tubes  and  in  the  intramural  ab- 


30    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

scess.  This  case  appeared  to  have  been  one  in  which  tuberculosis  was 
implanted  by  hemogenous  infection  upon  the  preexisting  gonococcal 
lesions.  Whether  the  intramural  abscess  was  originally  the  work  of 
the  gonococcus,  it  is  impossible  positively  to  determine.  This  case  has 
been  previously  reported  by  the  author.20 

Tuberculous  Deciduitis. — This  condition  may  result  from  a  pre- 
existing tuberculous  endometritis,  or  the  infection  may  occur  subse- 
quently to  conception.  The  histologic  picture  naturally  varies  with  the 
advancement  of  the  pregnancy  and  the  stage  of  the  lesion.  On  macro- 
scopic examination  the  decidua  may  be  found  thickened,  or  may  be 
normal  in  depth.  It  is  red,  congested,  and  the  surface  is  likely  to  pre- 
sent more  or  less  evidence  of  necrosis  and  may  be  partially  covered  by 
fibrin,  lymph,  and  caseous  material.  In  some  specimens  described  the 
decidua  has  appeared  normal  to  the  naked  eye,  and  in  others,  although 
evidently  the  seat  of  an  inflammation,  no  changes  characteristic  or  even 
suggestive  of  tuberculosis  have  been  observed. 

Histologic  Examination. — Histologic  examination  shows  that  the 
chief  changes  produced  in  the  decidua  by  infection  with  tubercle  bacilli 
are  necrosis  of  the  tissue  and  thrombi  in  the  venous  sinuses.  Typical 
tubercles  and  the  formation  of  giant  cells,  so  characteristic  of  tubercu- 
losis in  other  parts  of  the  female  genital  tract,  do  not  occur  in  the  de- 
cidua, although  they  may  be  present  in  the  myometrium  underlying  the 
basal  decidua,  or  less  frequently  a  tendency  toward  the  formation  of 
ill  defined  giant  cells  may  be  observed  in  the  deeper  layers  of  the  decidua. 
Tubercles  are  not  formed  from  the  decidua  cells.  Runge,21  in  the  first 
recorded  case  of  tuberculosis  of  the  decidua,  commented  upon  the  ab- 
sence of  tubercles  and  giant  cells,  and  explained  it  upon  the  basis  of  the 
transient  character  of  the  decidua  and  its  slight  capacity  for  prolifera- 
tion, the  latter  being  proved  by  the  rarity  of  tumors  in  the  decidua. 
YVarthin  22  explains  the  phenomena  by  stating  that  the  stroma  cells  in 
their  transformation  into  decidua  cells  have  already  passed  into  an 
epithelioid  form  and  are  incapable  of  further  proliferation  under  the 
action  of  such  stimuli  as  tubercle  bacilli.  In  the  nine  cases  reported  by 
Schmorl  and  Geipel  23  tubercles  and  giant  cells  were  absent  from  the 
decidua  in  every  case.  Similar  findings  are  observed  by  Wollstein,24 
Westenhoffer,25  the  author,  and  others.  The  degree  of  necrosis  varies 
markedly  in  different  cases,  but  this  change  is  usually  pronounced  and, 
combined  with  the  aforementioned  thrombi,  should  in  all  cases  put  the 
pathologist  upon  his  guard  for  this  type  of  infection.  The  necrotic 
areas  resulting  from  tuberculosis  must  be  distinguished  from  the  necrosis 
which  is  normally  present  in  the  placenta  at  times.     In  the  lesions  pro- 


PATHOLOGY  31 

duced  by  tube-culosis,  there  is  usually  marked  karyorrhexis  of  the 
lymphocytes  and  of  the  polymorphonuclear  leukocytes,  and  in  other  speci- 
mens a  well  marked  caseous  degeneration,  all  of  which  points  are  ab- 
sent in  the  normal  placenta.  In  addition  to  necrosis  and  thrombi,  the 
usual  evidences  of  a  deciduitis  are  present  and  are  characterized  by  the 
production  of  an  inflammatory  exudate,  composed  of  serum,  small  round 
cells,  plasma  cells  and  polymorphonuclear  leukocytes,  varying  in  inten- 
sity according  to  the  stage  of  the  disease.  The  stroma  cells  are  often 
edematous  and  take  the  stains  poorly.  The  cell  outlines  are  indistinct 
and  the  nucleus  stain  moderately  deep.  The  blood  vessels  are  markedly 
congested.  Even  in  the  same  specimen  variations  in  degree  of  inflam- 
matory reaction  are  often  marked  and  are  of  frequent  occurrence. 


PLACENTAL  TUBERCULOSIS 

Macroscopic  Appearance. — The  presence  of  tubercle  bacilli  in  a 
placenta  does  not  by  any  means  necessitate  macroscopic  or  even  histologic 
changes  being  present.  Tuberculosis  apparently  exerts  no  influence  on 
the  size  of  the  organ.  Nearly  all  the  tuberculous  placentas  which  have 
been  described  have  corresponded  closely  in  this  respect  to  the  normal, 
and  this  has  been  our  own  experience  in  a  fairly  large  series  of  cases. 
The  area  in  which  changes  are  most  likely  to  occur  is  at  the  base  near 
the  insertion  of  the  cord.  In  Wollstein's 24  case,  a  triangular  area 
5x7  cm.  with  the  apex  near  the  insertion  of  the  cord  was  present.  This 
area  was  yellow,  soft  and  somewhat  cheesy.  This  area  of  degeneration 
extended  to  and  involved  the  membranous  surface.  In  some  reported 
cases  a  number  of  cheese-like  areas  have  been  observed.  These  vary  in 
size.  The  maternal  and  fetal  surfaces  are  often  somewhat  rougher 
than  normal.  In  some  specimens  small  elevations  resembling  tubercles 
have  been  observed.  Smears  from  the  degenerated  cheesy  areas  show 
tubercle  bacilli.  The  cord  is  as  a  rule  normal.  The  uterus  in  these 
cases  is  apt  to  be  slightly  enlarged,  flabby,  and  the  peritoneal  surface  may 
show  tubercles.  Schmorl  and  Geipel 23  have  described  four  varieties  of 
placental  tuberculosis:  (1)  On  the  periphery  of  the  villi;  (2)  in  the 
stroma  of  the  villi;  (3)  in  the  basal  decidua  and  (4)  in  the  chorion  in- 
volving also  the  amnion.  Warthin  22  classifies  tuberculosis  of  the  pla- 
centa as  follows:  (1)  Decidual,  (2)  intervillous,  (3)  intravillous,  (4) 
intravascular  chorionic,  and  (5)  chorioamniotic.  This  is  practically  the 
same  as  that  of  Schmorl  and  Geipel  with  the  addition  of  the  intra- 
vascular chorionic  variety,  which  is  due  to  the  development  of  tubercle 


32  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

bacilli  in  the  blood  vessels  of  the  villi  or  chorionic  stems,  resulting  in  a 
primary  lesion  of  the  endothelium  of  the  vessel,  followed  by  secondary 
thrombosis.  The  later  organization  of  the  thrombus  by  epithelioid  cells 
derived  from  the  connective  tissue  of  the  vessel  wall  gives  an  intra- 
vascular tubercle.  Of  these  five  forms  of  tuberculosis  of  the  placenta, 
the  first  is  the  most  common  and  is  especially  apt  to  be  observed  in  full 
term  placentas.  The  second  or  intervillous  lesions  are  frequent. 
Warthin  —  described  this  variety  as  follows :  Throughout  the  inter- 
villous spaces  there  are  small,  round,  deeply  stained  areas  composed  of 
firmly  granular  or  hyaline  substance,  containing  lymphocytes  and  poly- 
morphonuclear leukocytes  in  varying  stages  of  disintegration.  The  ma- 
jority of  these  areas  are  about  the  size  of  a  pin  head,  or  somewhat 
smaller.  They  take  the  eosin  stain  more  deeply  than  the  hyaline  fibrous 
masses  which  are  formed  normally  in  the  intervillous  spaces;  but  the 
fragmentation  and  diffusion  of  the  nuclei  of  the  leukocytes  give  to 
many  of  them  a  bluish  tinge.  In  their  general  characteristics  they  re- 
semble the  hyaline  thrombi  of  the  decidual  vessels.  Varying  numbers 
of  tubercle  bacilli  are  present,  some  in  the  thrombi  as  well  as  a  few  in 
the  intervillous  blood  spaces.  In  single  sections  the  tuberculous  thrombi 
often  appear  lying  between  or  adjacent  to  villi  covered  with  syncytium, 
showing  apparently  no  pathologic  changes.  In  other  instances  they  ap- 
pear to  be  lying  free  in  the  blood  spaces.  Serial  sections,  however,  show 
that  in  old  cases  the  thrombi  are  attached  to  a  villus  at  some  point  where 
the  syncytium  has  either  vanished  or  was  present  as  a  swollen  hyaline 
layer  devoid  of  nuclei.  In  many  cases  the  necrosis  of  the  syncytium 
presents  a  firmly  granular  appearance,  suggestive  of  a  beginning  casea- 
tion. A  similar  change  may  be  seen  in  some  of  the  thrombi.  In  those 
cases  in  which  the  syncytium  is  absent  and  the  thrombi  are  resting  di- 
rectly upon  the  stroma  of  the  villi,  the  latter  in  many  instances  present 
evidence  of  epithelioid  proliferation  at  the  point  of  contact.  In  some 
instances  epithelioid  cells  and  typical  Langhans'  giant  cells  are  present, 
extending  from  the  stroma  of  the  villus  into  the  thrombi.  Thrombi  may 
be  demonstrated,  which  are  being  organized  by  epithelioid  tissue  arising 
from  the  stroma  of  the  villi  and  are  thus  changed  into  typical  tubercles. 
Giant  cells  are,  as  a  rule,  numerous  and  large.  In  many  thrombi  the 
only  evidence  of  epithelioid  changes  is  found  in  solitary  giant  cells, 
and  these,  although  apparently  occupying  the  center  of  the  thrombus, 
possess  long  protoplastic  processes  continuous  with  the  stroma  of  the 
villus.  In  those  thrombi  which  rest  upon  necrotic  syncytium  no  tuber- 
cles or  giant  cells  are  found.  This  tends  to  prove  their  origin  from  the 
stroma  of  the  villus  and  not  from  the  syncytium.     The  primary  lesion 


PATHOLOGY  33 

in  the  production  of  intervillous  tuberculosis  appears  to  be  a  degenera- 
tion or  necrosis  of  the  syncytium.  Here  an  agglutinative  thrombus 
forms,  composed  of  leukocytes,  red  blood  corpuscles,  or  blood  plaques 
from  the  maternal  blood.  Epithelioid  organization  from  the  stroma  of 
the  villi  next  occurs  and  the  tubercles  thus  formed  later  undergo  casea- 
tion. Schmorl  and  Geipel  23  are  of  the  opinion  that  the  epithelioid  cells 
originate  either  from  lymphocytes  or  from  the  fixed  cells  of  the  stroma 
of  the  villi.  Warthin  22  emphasizes  his  opinion  that  the  placenta  has 
no  especial  protection  against  tuberculosis.  In  the  event  of  tubercle  ba- 
cilli gaining  access  to  the  maternal  blood  stream,  the  chances  in  favor 
of  placental  localization  are,  he  thinks,  as  great  as  those  of  any  other 
organ.  This  does  not  entirely  coincide  with  the  author's  experiences, 
in  that,  in  the  large  proportion  of  cases  in  which  tubercle  bacilli  are 
present  in  the  placenta,  histologic  changes  were  present  only  in  a  small 
minority. 

Intravillous  Tuberculosis. — Schmorl  and  Geipel  23  regard  this  type 
of  tuberculosis  of  the  placenta  as  very  rare,  having  observed  it  but  once 
in  their  series  of  specimens ;  in  Warthin's  22  cases,  however,  although 
not  so  numerous  as  the  intervillous  tubercles,  the  intravillous  lesions 
were  common.  In  this  variety  tubercles  are  present  in  the  stroma  of 
villi  whose  syncytium  is  normal  and  independent  of  intervillous  thrombi, 
as  shown  in  serial  sections.  The  lesions  present  all  the  characteristics 
of  tubercles,  and  giant  cells  may  be  present  in  various  stages  from  the 
first  localized  necrosis  to  advanced  caseation.  The  syncytium  remains 
normal  until  the  caseation  reaches  the  subsyncytium  layer  of  the  stroma, 
after  which  the  villus  covering  becomes  necrotic  and  a  thrombus  forms 
at  the  site  of  the  injured  syncytium.  Tubercle  bacilli  can  usually  be 
demonstrated  without  difficulty  in  the  caseous  lesions.  Warthin  very 
properly  points  out  that  the  presence  of  intravillous  tubercles  in  the 
absence  of  syncytial  lesions  must  be  considered  as  strong  evidence  that 
the  bacilli  have  passed  through  the  syncytium  without  damaging  it,  and 
have  produced  their  characteristic  changes  first  in  the  stroma  of  the 
villus.  Further  evidence  pointing  to  this  conclusion  is  the  absence  of 
thrombi  upon  the  syncytium  in  the  early  stages.  In  addition,  the  fact 
that  intravillous  tubercles  are  present  in  cases  in  which  there  are  no 
tubercles  in  the  fetus  would  seem  further  proof  of  the  above  assertion, 
as  it  is  not  probable  that  the  chorionic  villi  would  alone  show  tubercles, 
if  the  dissemination  occurred  by  metastasis  directly  through  the  fetal 
blood  stream,  while  a  retrograde  metamorphosis  seems  still  less  likely. 
Schmorl  and  Geipel  23  offer  the  explanation  that  the  entrance  of  tubercle 
bacilli  may  occur  through  a  defect  in  the  syncytium,  or  an  infection  from 


34    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

the  fetal  blood  stream  through  a  direct  metastasis  after  passing  through 
the  fetal  body. 

Intravascular  Chorionic  Lesions. — This  is  a  rare  lesion,  but  is 
probably  similar  to  the  foregoing  in  the  method  of  formation.  In  this 
variety  tubercles  form  in  the  same  manner  as  previously  described. 
These  lesions  occur  in  the  vessels  of  the  chorion.  The  thrombi  may 
entirely  obliterate  the  lumen  of  the  vessel,  or  may  partially  occlude  it. 
They  are  similar  in  appearance  to  the  intervillous  thrombi  and  are 
deeply  staining  hyaline  or  granular  masses  composed  of  broken  up 
chromatin.  The  vessel  walls  at  the  site  of  the  thrombi  often  show 
beginning  necrosis.  The  epithelioid  cells  of  the  tubercles  develop  from 
the  vessel  walls.    Warthin  demonstrated  tubercle  bacilli  in  these  thrombi. 

Chorio-Amniotic  Variety. — Warthin 22  states  that  secondary  in- 
volvement of  the  amnion  by  large  caseating  or  epithelioid  tubercles  of 
the  chorion  was  observed  by  him  a  few  times.  The  portion  of  the 
amnion  in  the  neighborhood  of  the  chorionic  tubercles  was  thickened, 
infiltrated  with  leukocytes,  and  showed  a  beginning  caseation.  Tubercle 
bacilli  were  demonstrated  in  the  caseous  area.  Schmorl  and  Geipel  23 
have  described  similar  lesions.  One  or  all  of  these  varieties  of  tubercu- 
losis may  be  present  in  a  single  specimen. 

In  one  of  the  cases  examined  by  the  author  some  of  the  tubercles 
exhibited  a  well  marked  tendency  toward  healing.  Similar  changes  were 
observed  by  Warthin 26  in  a  recently  described  case.  Many  of  the 
tubercles  in  his  case  showed  no  caseation,  or  only  slight  central  caseous 
changes.  Tubercle  bacilli  could  not  be  found  in  the  healing  tubercles, 
but  were  demonstrated  in  those  which  were  caseous.  Healing  tubercles 
must  be  differentiated  from  infarcts,  which  can  easily  be  accomplished 
by  noting  their  circumscribed  shape  and  by  the  fibroplastic  proliferation 
of  the  villi  induced  in  the  primary  intervillous  thrombus,  which  forms 
a  condensed  mass  of  epithelioid  cells.  Warthin  further  calls  attention 
to  the  need  for  differentiation  from  small  localized  areas  of  syphilitic 
chorionitis  and  small  infarcts  showing  reparative  changes.  He  states 
that  in  the  former  the  syphilitic  process  involves  only  the  stroma  of  the 
villi  and  the  latter  are  not  fused  with  the  solid  fibroplastic  or  fibroid 
mass;  and  in  the  healing  infarcts  the  villi  may  be  fused,  but  there  is  an 
absence  of  fibroplastic  tissue,  or  only  a  small  amount  present.  The  heal- 
ing tubercles  may  show  the  outlines  of  some  villi  fused  into  an  intervil- 
lous epithelioid  or  fibroplastic  proliferation.  In  all  cases  of  doubt,  the 
presence  of  tubercle  bacilli  in  the  smears  or  sections  or,  as  a  final  step, 
animal  inoculation  will  prove  the  character  of  the  lesion. 

Tuberculosis  of  the  Fallopian  Tubes. — The  fallopian  tube  is  the 


PATHOLOGY  35 

most  frequent  area  infected  by  the  tubercle  bacilli  in  the  female  genital 
tract.  Jellett  27  states  that  tuberculosis  of  the  fallopian  tubes  is  the 
commonest  form  of  tuberculosis  in  women,  with  the  exception  of  the 
pulmonary  variety.  The  susceptibility  of  the  fallopian  tubes  to  tuber- 
culous infection  is  explained  by  Pozzi  28  on  the  ground  that  the  mucosa 
of  these  organs  offers  a  favorable  nidus  for  infection  in  conjunction 
with  the  changes  which  occur  at  menstruation  and  is  easily  accessible 
to  organisms  from  tuberculous  peritonitis.  It  has  been  shown  experi- 
mentally in  animals  that,  if  fine  granules  are  injected  into  the  peritoneal 
cavity,  some  of  the  material  finds  its  way  into  the  fallopian  tubes  and 
can  ultimately  be  demonstrated  in  the  discharge  in  the  vagina.  The 
infection  may  result  from  blood  carried  organisms  and  by  direct  exten- 
sion, or  infection  may  occur  by  way  of  the  lymphatics,  the  most  fre- 
quent form  probably  being  a  secondary  infection  from  the  lungs,  although 
some  investigators  think  infection  by  way  of  the  peritoneum  the  most 
common.  This  certainly  is  not  infrequent.  On  the  other  hand,  a 
hemogenic  or  other  form  of  infection  of  the  tubes  may  be  followed  by  a 
general  peritonitis.  Direct  extension  from  the  endometrium  may  occur, 
but  the  converse  is  more  common.  Direct  extension  may  also  result 
from  adherent  foci,  such  as  tuberculous  lesions  in  the  intestines,  but  here 
again  the  converse  may  occur. 

For  the  purpose  of  pathologic  study  tuberculous  lesions  of  the  fal- 
lopian tubes  may  be  classified  under  the  heading  of  perisalpingitis,  sal- 
pingitis, pyosalpingitis  and  hydrosalpingitis. 

Perisalpingitis. — This  variety  of  lesion  is  not  infrequently  the  re- 
sult of  a  secondary  infection  from  the  peritoneum.  Tuberculous  infec- 
tion of  the  serosa  of  the  fallopian  tubes  without  involvement  of  the 
deeper  coats  is  by  no  means  frequent,  and,  although  many  specimens  are 
observed  which,  upon  macroscopic  examination,  present  no  pathologic 
changes  except  adhesions,  histologic  examination  will  usually  reveal 
definite  involvement  of  the  muscularis  or  mucosa  or  of  both.  In  peri- 
salpingitis the  tubes  are  as  a  rule  normal  in  size,  the  abdominal  ostium 
open,  and  the  surface  shows  adhesions.  The  adhesions  may  cause  con- 
siderable distortion  of  the  tube  while  in  situ,  but  after  removal  the 
lesions  are  less  pronounced.  Macroscopic  tubercles  may  or  may  not  be 
present  in  the  serosa.  Their  presence  is,  however,  usually  an  indication 
of  an  involvement  of  the  deeper  coats  of  the  tube. 

Histologically  these  tubes  present  no  lesions  beyond  the  above  men- 
tioned adhesions,  and  characteristic  tubercles  are  comparatively  infre- 
quent, a  number  of  sections  not  infrequently  having  to  be  examined 
before  the  etiology  of  the  condition  can  be  determined. 


36  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Salpingitis. — As  a  rule  the  mucosa  is  the  first  portion  of  the  tube 
attacked,  and  from  thence  the  infection  spreads  until  finally  all  the  coats 
are  involved,  the  ampulla  being  generally  the  first  part  of  the  tube  to  be 
invaded.  A  study  of  the  specimens  in  the  gynecological  laboratory  of 
the  University  of  Pennsylvania  shows  that  slightly  less  than  50  per  cent 
of  cases  of  tuberculosis  of  the  tubes  were  suspected  prior  to  the  histologic 
examination,  and  this  despite  the  fact  that  all  specimens  are  sub- 
jected to  a  macroscopic  as  well  as  a  histologic  examination.  In 
Williams's  29  report  only  25  per  cent  were  of  the  suspected  variety.  The 
presence  of  tubercles  on  the  peritoneal  surface  of  the  tube,  the  fact  that 
in  this  form  of  infection  the  abdominal  ostium  is  more  prone  to  remain 
patulous  than  in  any  other  variety  of  infection,  the  presence  of  cheesy 
material  within  the  lumen  or  adherent  to  the  fimbria  at  the  abdominal 
ostium,  and  the  fact  that  these  lesions  are  seldom  seen  in  their  early 
stages,  the  usual  bilateral  characters  of  the  infection,  are  all  points  that 
should  make  the  examiner  suspicious  of  tuberculosis.  The  tendency 
toward  patency  of  the  external  abdominal  ostium  in  tubes,  the  seat  of 
this  variety  of  infection,  is  most  marked.  Although  contractures  at  this 
point  are  frequent,  actual  occlusion,  as  compared  with  other  varieties  of 
tubal  inflammation,  is  unusual,  and  even  when  the  external  end  of  the 
tube  is  entirely  closed,  the  fimbria  can  usually  be  seen  plastered  down 
over  the  closed  off  end  of  the  tube,  a  condition  that  is  rarely  present  in 
lesions  the  result  of  organisms  other  than  the  tubercle  bacilli.  In  one 
form  of  tuberculosis  small  nodules  are  present,  especially  in  the  isthmus 
of  the  tube,  somewhat  resembling  at  first  glance  a  small  fibroma.  This 
variety  is  spoken  of  as  a  salpingitis  isthmiae  nodosa.  In  the  early  stages 
tuberculous  salpingitis  does  not  as  a  rule  present  very  acute  symptoms, 
and  indeed  is  usually  prone  to  run  a  somewhat  chronic  course,  so  that 
in  this  form  of  infection  subjective  symptoms  are  apt  to  be  less  marked 
than  in  the  gonococcic  or  streptococcic  varieties,  and  as  a  result  speci- 
mens are  rarely  seen  in  the  early  stages.  An  exception  to  this  is  some- 
times observed  in  autopsy  specimens  and  in  late  infection  from  miliary 
tuberculosis.  The  above  comprise  the  chief  diagnostic  features  of  tuber- 
culosis of  the  fallopian  tubes;  although  none  are  positive  they  are  ex- 
tremely suggestive  of  this  form  of  infection.  In  about  one  half  the 
specimens  nothing  even  suggestive  of  tuberculosis  can  be  detected  by 
macroscopic  examination  alone,  the  tubes  in  these  instances  resembling 
organs  the  seat  of  ordinary  inflammatory  lesions.  For  this  reason 
statistics  regarding  the  frequency  of  tuberculosis  of  the  fallopian  tubes 
are  likely  to  be  misleading,  unless  based  upon  histologic  as  well  as  macro- 
scopic examination. 


PATHOLOGY  37 

Tubes  the  seat  of  tuberculous  infection  vary  widely  in  appearance. 
Except  in  salpingitis  isthmiae  nodosa,  the  ampulla  is  the  portion  of  the 
tube  in  which  the  pathologic  process  is  most  marked.  The  tubes  may  be 
normal  in  size  or  greatly  enlarged.  Violet 30  has  especially  called  atten- 
tion to  the  hypertrophy  of  the  tubes  which  may  result  from  tuberculous 
infection.  The  surface  is  usually  the  seat  of  numerous  adhesions,  and 
as  the  disease  is  prone  to  be  chronic,  these  are  likely  to  be  dense.  In  the 
late  stages  or  in  those  cases  that  are  secondary  to  tuberculous  peritonitis, 
macroscopic  tubercles  are  often  discernible.  Caseous  material  is 
sometimes  present  at  the  external  abdominal  ostium,  and  is  often  ob- 
served adherent  to  the  fimbriae ;  in  advanced  cases  the  entire  peritoneal 
surface  may  be  coated  with  yellowish  gray  cheesy  material.  The  peri- 
toneum covering  the  tube  is  red  and  inflamed.  Similar  changes  may  be 
observed  on  the  surface  of  the  uterus  and  ovaries.  On  section,  the  walls 
of  the  tube  may  be  found  much  thickened ;  in  other  specimens  the  walls 
may  be  normal  in  depth.  The  lumen,  unless  the  abdominal  ostium  is 
closed,  is,  as  a  rule,  not  greatly  enlarged.  The  mucosa  is  generally  thick- 
ened and  congested,  but  as  a  result  of  necrosis  may  be  entirely  absent. 
In  some  specimens,  as  a  result  of  thickening  of  the  mucosa,  the  lumen  is 
greatly  reduced  in  size,  and  on  section  presents  somewhat  the  appear- 
ance of  the  ordinary  pseudo  follicular  hydrosalpinx.  The  lumen  may  be 
macroscopically  empty,  or  may  contain  creamy  pus,  cheesy  material,  or 
watery  fluid.  The  muscularis  is  generally  thickened  and  edematous. 
Occasionally  the  tuberculous  process  has  apparently  been  somewhat 
checked  and  retrogressive  changes  are  observed.  Restoration  to  the 
normal  is,  however,  less  frequent  in  tuberculosis  than  in  other  forms 
of  infection.  In  this,  as  in  all  forms  of  adnexal  tuberculosis,  calcareous 
deposits  are  sometimes  present,  perhaps  more  frequently  in  tuberculosis 
than  in  any  other  variety  of  infection. 

In  salpingitis  isthmiae  nodosa  the  tubes  may  be  normal  in  size  or 
may  be  somewhat  elongated  and  slightly  enlarged  in  diameter.  This 
form  of  tuberculosis  does  not,  however,  usually  result  in  massive  lesions, 
the  chief  feature  being  that  small  firm  fibrous  nodules  are  present,  chiefly 
in  the  inner  and  middle  third  of  the  tube;  these  vary  from  slight  enlarge- 
ments to  small  tumor-like  masses  one  or  two>  or  even  more  centimeters 
in  diameter.  On  section  through  one  of  these  nodules  they  are  found  to 
be  firm  and  fibrous  in  consistency;  the  lumen  of  the  tube,  which  may 
pass  through  the  center  or  eccentrically,  is  reduced  in  size,  often  being 
no  larger  than  a  pin  hole.  What  appear  to  be  multiple  lumina  are  often 
observed;  histologic  examination  of  these,  however,  shows  that  they  are 
pseudoglands. 


38    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Bell 31  recognizes  two  forms  of  tuberculosis  of  the  fallopian  tubes, 
the  miliary  and  the  caseous;  but  while  well  defined  instances  of  these 
forms  are  often  observed,  more  frequently  this  is  not  the  case. 

Pyosalpinx. — This  as  a  rule  represents  the  end  stage  of  a  salpingitis. 
In  those  cases  in  which  the  abdominal  ostium  finally  becomes  closed, 
resulting  in  a  pyosalpinx,  the  fimbria  can  usually  be  observed  plastered 
over  the  closed  end  of  the  tube.  The  actual  method  of  closure  of  the 
external  abdominal  ostium  is  still  somewhat  in  doubt.  Doran,32  Klein- 
haus,33  Opitz,34  Reis,35  and  Young36  have  devoted  papers  to  a  descrip- 
tion of  the  manner  of  closure  of  pyosalpinges  in  general..  The  last  named 
observer  summarizes  the  various  theories  as  follows,  dividing  them  into 
two  classes :  Class  I  includes  those  theories  based  upon  the  increase  in 
the  total  length  of  the, tube  wall,  which,  by  expanding  in  an  outward 
direction,  becomes  projected  beyond  the  tubal  fimbria.  According  to  the 
theory  of  Doran  and  Kleinhaus,  the  increase  in  length  is  dependent  on 
the  swelling  and  increase  in  the  substance  of  the  tube  wall,  associated 
with  the  inflammation.  Reis  believes  the  gliding  outward  of  the  "peri- 
toneal ring"  over  the  fimbria  is  rendered  possible  by  the  fact  that  the 
walls  are  loose  and  redundant  subsequent  to  the  collapse  of  the  distended 
tube.  In  Class  II  are  included  the  theories  of  Opitz  and  Young.  The 
first  explains  the  process  as  due  to  retraction  of  the  muscularis  and 
mucosa  of  the  tube  within  the  serous  coat;  and  the  latter  claims  that  the 
gliding  process  involves  only  the  inner  coat  of  the  muscularis.  The  so- 
called  perimetritic  closure  of  Doran  is  explained  by  the  matting  together 
of  the  fimbria  by  inflammatory  adhesions  without  preliminary  recession. 
In  many  instances  the  intramural  portion  of  the  tube  probably  becomes 
occluded  somewhat  earlier  than  does  the  external  abdominal  ostium; 
This  occlusion  is  the  result  of  agglutination  of  the  mucosa.  In  some 
cases  this  becomes  permanent,  whereas  in  others  leakage  occurs  at  irreg- 
ular intervals.  In  some  specimens  the  occlusion  at  the  inner  portion  of 
the  tube  is  largely  mechanical,  as  a  result  of  a  kink  or  bend.  The  above 
applies  to  pyosalpinges  in  general. 

Serial  sections  have  been  made  by  the  author  through  the  occluded 
outer  end  of  a  number  of  tuberculous  fallopian  tubes.  From  this  study 
it  would  appear  that  the  fimbria  of  the  tube  is  attacked  early  in  the  dis- 
ease and  that,  as  a  result  of  infection,  it  becomes  first  swollen  and  then 
often  adherent  to  the  peritoneal  coat  of  the  tube,  and  that,  as  subsequent 
closure  occurs,  the  swollen  and  adherent  fimbria  being  attached  outside 
the  tube,  cannot  be  withdrawn  inside  the  lumen,  thus  accounting  for  the 
frequency  with  which  the  fimbrias  are  observed  plastered  externally  on 
the  occluded  ends  of  tuberculous  pyosalpinges.     The  facts  that  tuber- 


PATHOLOGY  39 

culosis  usually  attacks  the  outer  end  of  the  tube  primarily,  and  that  the 
onset  is  often  chronic,  probably  account  for  the  greater  frequency  with 
which  the  fimbria  are  visible  in  tuberculous  than  in  other  varieties  of 
pyosalpinges. 

Pyosalpinges  of  tuberculous  origin  vary  markedly  in  size,  but  in  some 
instances  grow  to  enormous  dimensions.  Some  of  the  largest  tubal 
abscesses  which  the  author  has  seen  have  been  of  this  variety  of  infec- 
tion. The  surface  is  usually  more  or  less  covejed  with  adhesions,  and 
this  is  apt  to  be  especially  pronounced  in  those  cases  which  are  secondary 
to  a  tuberculous  peritonitis.  The  walls  vary  much  in  thickness,  but  as  a 
rule  in  very  large  specimens  they  are  moderately  thin.  This  tendency 
for  the  walls  to  be  thin  in  large  pyosalpinges  is  perhaps  more  marked  in 
the  tuberculous  than  in  other  types  of  infection.  Indeed,  in  gonorrheal 
pyosalpinges  it  may  be  stated  that  the  thickness  of  the  walls  has  practi- 
cally no  relation  to  the  size  of  the  lumen. 

Not  infrequently  a  pyosalpinx  may  be  present  on  one  side  and  a 
salpingitis  on  the  other.  The  lumen  in  advanced  cases  is  usually  necrotic, 
covered  with  cheesy  material,  and  what  mucosa  remains  is  red  and  in- 
flamed. The  contents  of  the  lumen  varies ;  it  is  often  caseous  material,  or 
may  be  thick  creamy  pus,  sometimes  blood  streaked ;  more  rarely  the  pus 
is  moderately  thin  and  dark  in  color. 

Hydrosalpinx. — As  the  result  of  a  tuberculous  infection  of  the  tube, 
hydrosalpinx  occasionally  occurs.  In  these  specimens  the  walls  tend  to 
thin  out,  and  the  infection  is  not  as  a  rule  active.  The  usual  type  of 
hydrosalpinx  is  the  pseudofollicular  variety.  The  mucosa  is  generally 
thickened,  the  actual  lumen  often  being  small,  and  the  tube  presents  on 
cut  section  a  honeycombed  appearance,  the  compartments  varying  con- 
siderably in  size,  but  generally  being  small.  The  contents  are  thin,  watery 
material,  sometimes  colorless,  but  more  often  presenting  a  slightly  yel- 
lowish or  amber  tint.  Tubercle  bacilli  can  rarely  be  demonstrated  in 
these  specimens,  whereas  in  the  tube,  the  seat  of  a  purulent  collection,  the 
specific  organism  can  often  be  found  with  no  great  difficulty. 

Histologically,  tubes  the  seat  of  this  variety  of  infection  present  the 
usual  evidence  of  an  inflammatory  infiltration,  generally  chronic  in  char- 
acter, plus  the  characteristic  tubercles,  some  of  which  will  be  found  to 
contain  giant  cells.  The  tubercles  are  not  limited  to  the  mucosa,  but 
may  also  be  present  in  the  muscularis.  In  the  absence  of  bacteriologic 
proof,  the  presence  of  tubercles  is  the  only  characteristic  of  this  variety 
of  infection  upon  which  a  positive  diagnosis  can  be  based.  Certain  other 
characteristics  exhibited  by  tuberculosis  are  extremely  suggestive.  Necro- 
sis of  the  mucosa,  sometimes  amounting  to  an  entire  absence  of  this 


4o    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

layer  of  the  tube,  is  of  frequent  occurrence,  and  is  found  perhaps  more 
often  in  this  infection  than  in  tubes  the  seat  of  an  ordinary  pyogenic 
invasion.  A  form  of  tubal  tuberculosis  which  is  not  infrequent  is  that 
in  which  the  tips  of  the  mucosa  folds  are  agglutinated,  forming  numerous 
pseudo  glands.  These  vary  in  size  and  shape,  but  are  usually  moderately 
small.  The  epithelium  is  not  desquamated,  but  on  the  contrary  exhibits 
a  well  marked  tendency  toward  reduplication,  sometimes  as  many  as  four 
or  five  layers  being  presept  in  some  areas.  Together  with  the  reduplica- 
tion, the  individual  cells  are  themselves  altered  and  present  more  or  less 
irregularity,  alike  as  to  size,  shape,  and  staining  properties.  Often  the 
nuclei  are  hyperchromatic  and  occasionally  exhibit  karyokinetic  changes. 
At  first  glance,  especially  in  the  absence  of  tubercles  or  giant  cells,  such 
an  appearance  is  strongly  suggestive  of  carcinoma.  A  more  careful  ex- 
amination, however,  dispels  this  theory,  whereas  the  epithelial  cells 
are  reduplicated  and  somewhat  irregular  and  possess  deeply  staining 
nuclei;  they  are  not  of  the  cancer  type,  nor  is  there  any  penetration  of 
the  basement  membrane.  To  dissipate  any  further  doubt,  a  search 
through  a  number  of  sections  is  almost  sure  to  reveal  one  or  more  char- 
acteristic tubercles.  A  few  instances  (Lipschitz,37  Saulman38)  have 
been  recorded  in  which  tuberculosis  and  cancer  have  been  present  coinci- 
dently  in  the  same  tube.  The  previously  described  lesions  can,  however, 
be  easily  differentiated  by  the  experienced  pathologist  from  carcinoma. 
The  tubes  in  which  this  condition  has  been  observed  by  the  author  are 
usually  of  moderate  size  and  the  external  abdominal  ostium  may  or  may 
not  be  closed.  Barbour  and  Watson  39  and  others  have  reported  cases 
of  this  type,  and  have  observed  penetration  of  the  muscularis  as  a  result 
of  proliferation  of  the  epithelium,  as  well  as  the  formation  of  strands 
and  masses  of  epithelium  in  the  substance  of  the  mucosa.  Evidence  of 
destruction  of  the  surface  epithelium  is  also  present.  In  forms  other 
than  the  caseous  variety,  and  excepting  the  presence  of  tubercles  and 
tuberculous  giant  cells  and  bacteriologic  evidence,  proliferation  of  the 
epithelium  of  the  mucosa  is  one  of  the  chief  characteristics  of  tubercu- 
losis in  this  area.  In  the  pseudocancerous  variety  there  is  little  or  no 
tendency  toward  desquamation,  even  when  the  disease  is  advanced. 

The  epithelium  cells  may  enlarge  or  lose  their  cilia.  The  nuclei  swell 
and  often  occupy  almost  the  entire  cell. 

In  the  chronic  stage  of  tuberculous  salpingitis,  there  is  often  an 
excessive  formation  of  connective  tissue,  and  calcareous  formation  is  not 
uncommon. 


PATHOLOGY  41 

TUBERCULOSIS  OF  THE  OVARY 

The  ovary  possesses  a  well  defined  resistance  to  infection  by  tubercle 
bacilli.  Indeed,  until  comparatively  recent  years  tuberculosis  of  this 
organ  was  looked  upon  as  a  gynecologic  rarity.  As  late  as  1880  Bris- 
sand  40  stated  that  there  was  not  a  single  example  of  this  condition  in 
the  museum  of  the  College  of  France.  When  it  is  remembered  how 
frequent  is  tuberculosis  of  the  fallopian  tubes,  and  that  this  infection  is 
a  hematogenous  one  in  the  large  majority  of  cases,  and  the  close  anatomic 
relationship  between  the  tube  and  ovary,  it  is  surprising  that  the  latter  is 
not  more  frequently  attacked,  especially  as  it  is  the  ampulla  of  the  tube 
which  is  usually  primarily  invaded.  Whereas  a  true  infection  of  the 
substance  of  the  ovary  is  not  the  rule  when  the  tubes  are  involved,  peri- 
oophoritis of  tuberculous  origin  is  quite  frequent. 

Peri-oorphoritis. — This  tuberculous  affection  of  the  ovary  by  no 
means  indicates  an  actual  invasion  of  the  ovary  by  tubercle  bacilli.  These 
lesions  are  generally  secondary  to  tubal  tuberculosis,  but  may  be  the 
result  of  a  general  tuberculous  peritonitis.  In  either  event,  they  are 
caused  by  a  deposit  upon  the  surface  of  the  ovary  of  a  tuberculous 
exudate,  which  results  in  more  or  less  thickening  of  the  tunica  albuginea 
and  in  adhesions  to  adjacent  structures,  usually  the  posterior  layer  of 
the  broad  ligament,  the  external  end  of  the  tube,  the  omentum,  or  intes- 
tine. Upon  section,  the  ovarian  substance  is  usually  found  normal  and 
developing  follicles  are  generally  present.  As  a  result  of  the  thickening 
of  the  capsule  of  the  ovary,  a  tendency  toward  the  formation  of  retention 
cysts  occurs  and  one,  or  more,  of  these  is  likely  to  be  present,  if  the 
condition  has  been  of  long  standing.  The  cysts  are  usually  not  large, 
and  the  ovary  itself  is  generally  nearly  normal  in  size.  This  disposition 
of  the  ovarian  structure  to  remain  free  from  infection,  even  after  pro- 
longed contamination  of  the  surface,  is  of  importance  in  deciding  upon 
the  type  of  operation  to  be  performed  upon  patients  the  incumbents  of 
tuberculous  salpingitis. 

Oophoritis. — In  comparison  with  the  preceding  condition,  this  is 
a  comparatively  rare  lesion.  It  is  probably  usually  a  hematogenous  in- 
fection, although  the  possibility  of  invasion  from  the  surface  of  a  pre- 
viously contaminated  ovary  at  the  time  of  rupture  of  a  graafian  follicle 
must  be  considered.  As  seen  in  the  laboratory  or  upon  postmortem,  the 
infection  is  usually  in  the  chronic  stage,  and  the  ovaries  are,  as  a  rule, 
but  little  enlarged.  Retention  cysts  are,  however,  of  frequent  occurrence, 
and  are  usually  of  the  follicular  variety.     The  surface  of  the  organ  is 


42    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

generally  more  or  less  covered  with  adhesions,  and  the  capsule  somewhat 
thickened.  The  substance  of  the  ovary  may  be  slightly  firmer  than  nor- 
mal and  somewhat  congested,  but  otherwise  no  marked  macroscopic 
lesions  are  usually  present.  Less  frequently,  the  ovary  is  enlarged  and 
may  contain  one  or  more  abscesses,  the  contents  of  which  are  cheesy 
material  or  creamy  pus.  These  abscesses  may  be  interstitial  in  type  or 
may  result  from  the  infection,  either  hematogenous  or  from  without,  of 
either  a  graafian  follicle  or  corpus  luteum. 

Histologically,  the  surface  of  the  ovaries  presents  dense  adhesions, 
which  are  generally  quite  avascular.  The  capsule  is  more  or  less  thick- 
ened, not  always  uniformly.  The  ovarian  stroma  is  infiltrated  with 
chronic  inflammatory  products,  small  round  cells,  plasma  cells,  a  few 
polymorphous  nuclei,  leukocytes  and  exudate.  Often  the  stroma  is 
edematous.  The  blood  vessels  are  as  a  rule  congested.  Tubercles  and 
tubercular  giant  cells  are  here  and  there  present.  These  are  usually 
sparsely  distributed,  and  a  number  of  sections  may  have  to  be  studied 
before  the  characteristic  lesions  of  this  type  of  infection  are  detected. 
As  will  be  observed,  ovaries  the  seat  of  tuberculosis  present  no  diagnostic 
characteristics,  with  the  exception  of  tubercles.  When  abscesses  are 
present,  these  possess  a  lining  of  caseous  or  necrotic  material.  Typical 
tubercles  and  giant  cells  are  generally  present  in  moderate  numbers  in 
such  specimens.  Tubercle  bacilli  can,  as  a  rule,  be  demonstrated  only 
with  difficulty,  except  in  acute  or  very  advanced  lesions. 


LITERATURE 


i 

2 

3 

4 

5 
6 

7 
8 

9 
io 
ii 

12 

13 

14 


Cora,  E.    Gyn.  Rundsch.    1910.    4:318. 

Beyea,  H.  D.    Ann.  de  Gyn.  et  d'Obst.     1900.    54:169. 

Mayo,  W.  J.     Mayo  Clin.     1918.     10:146. 

Schramm.    Arch.  f.  Gyn.    v.  19. 

Orthman  und  Munson.    Arch.  f.  Gyn.    39  :gy. 

Rosenstein.     Monschr.  f.  Gebh.  u.  Gyn.     1907.    20:366,966. 

Hilschmann,  von  F.,  und  Adler,  L.    Arch.  f.  Gyn.     1913.    233. 

Strong,  L.  W.     Am.  Jr.  Obst.     19 19.     80:139. 

Osiander.     Hann.  Ann.  f.  d.  Ges.  Heilk.     1840.     5  :pt.  1. 

Madlener.    Centrbl.  f.  Gyn.     1894.    p.  529. 

Zahn.    Virch.  Arch.  115  :66. 

Wassmer.     Arch.  f.  Gyn.     1899.     57:301. 

Gottschalk.     Int.  Cong.  Obst.  Gyn.     Rome,  1902. 

Papow.    Russi  Wratch.     1906.     3:12. 


PATHOLOGY  43 

Frome.    Centralbl.  f.  Gyn.    1909.    81  11093. 

Watkins,  T.  J.     Surg.  Gyn.  Obst.     1907.     5  :6o3. 

Roberts,  C.  H.    Proc.  Roy.  Soc.  Med.,  Sec.  Gyn.     191 1.    p.  57. 

Stewart,  M.  J.    Jr.  Path.  Bact.     191 1.     16:385. 

Alessandri.    La  gynecologia  moderna.     19 13. 

Norris,  C.  C.     Gonorrhea  in  Women.     Philadelphia  and  London, 

I9I3- 
Runge.    Arch.  f.  Gyn.     1903.     68:388. 
Warthin,  A.  S.    Jr.  Inf.  Dis.     1907.     4:347. 
Schmorl  und  Geipel.     Munch.  Med.  Woch.     1904.    2:1676. 
Wollstein,  M.    Arch.  Ped.     1905.    22:321. 
Westenhoeffer.     Deuts.   Med.   Woch.      1903.     29:221. 
Warthin,  A.  S.    Jr.  Am.  Med.  A.     1913.    61  :i95i. 
Jellett,  S.  W.    A  Short  Treatise  on  Gynecology.    London,  1908. 
Pozzi,  S.    A  Treatise  on  Gynecology.    New  York,  1897. 
Williams,  J.  W.    J.  Hopk.  Hosp.  Rep.    1894.    3:114. 
Violet.    Lyon  Med.     1912.     119:279. 

Bell,  W.  B.     The  Principles  of  Gynecology.     London,  &c,  1910. 
Doran,  A.    Tr.  Obst.  Soc.  Lond.    Dec.  4,  1889. 
Kleinhaus.    Veit's  Handb.    3 :69c 
Opitz.    Ztschr.  f.  Gebh.  u.  Gyn.    3  485. 
Reis,  E.    Am.  Jr.  Obst.    Aug.,  1909. 
Young,  J.    Jr.  Obst.  Gyn.  Brit.  Emp.     1910.     16:307. 
Lipschitz,  K.     Monschr.  f.  Gebh.  u.  Gyn.     1914.    39:11. 
Saulman.    Centrbl.  f.  Gyn.     1892.     16:533. 
Barbour,  A.  H.  F.,  and  Watson,  B.  P.    Jr.  Obst.  Gyn.  Brit.  Emp. 

1911.    21  1105. 
Brissand,  E.    Arch.  Gen.  de  Med.    1880.    146:129. 


CHAPTER  IV 

CONGENITAL  AND  PLACENTAL  TUBERCULOSIS 

Placental  transmission  of  tuberculosis — Conflicting  reports  of  findings — Types,  acute, 
chronic ;  errors  in  technic — Definition  of  congenital  tuberculosis — Discrimination 
between  congenital  infection  and  congenital  predisposition — Etiology — Germina- 
tive  infection  :  Spermatozoic — Variety  of  infection — Experiments  of  Waldstein  and 
Ekler — Observations  of  medical  experts — Unfertilized  ovum — Ovarian  infection 
and  germinal  transmission  of  disease — Congenital  germinative  tuberculosis — 
Placental  and  fetal  tuberculosis — Susceptibility — Opinion  of  Baumgarten  and 
others — Tubercle  bacilli  in  the  blood  stream — Histology  and  physiology  of  the 
placenta  in  relation  to  routes  of  transmission  of  tubercle  bacilli — Views  of  Delore 
and  other  investigators — Infarcts  described  by  Williams — Results  demonstrating 
congenital  or  placental  tuberculosis — Distinction  between  placental  infection  and 
fetal  involvement — Criticism — Period  at  which  intra-uterine  transmission  occurs 
— Predisposing  factors  to  placental  or  congenital  tuberculosis — Undoubted  cases 
— Anatomical  changes  and  presence  of  tubercle  bacilli — Histologic  changes  and 
presence  of  tubercle  bacilli — Demonstration  of  bacilli  by  staining  or  by  inocula- 
tion of  animals — Conclusions. 

The  subject  of  the  placental  transmission  of  tuberculosis  and  of 
placental  pathologic  lesions,  the  result  of  this  infection,  is  of  especial  in- 
terest. Quite  contradictory  findings  have  been  reported  regarding  the 
frequency  of  placental  tuberculosis.  Thus,  Schlimpert x  reported  having 
found  placental  tuberculosis  in  80  per  cent  of  a  series  of  cases ;  Novak  and 
Ranzel,2  in  70  per  cent ;  Schmorl  and  Geipel,3  in  40  per  cent.  Pankow,4 
on  the  other  hand,  in  a  series  of  20  placentas,  failed  to  demonstrate  a 
single  case,  and  Bossi  had  a  similar  experience.  As  a  result  of  these 
and  other  equally  conflicting  reports,  it  has  seemed  advisable  to  gather 
and  study  the  results  secured  in  an  extensive  series  of  cases,  with  the 
hope  of  throwing  some  light  upon  the  actual  frequency  of  placental  and 
congenital  tuberculosis.  At  the  outset  it  became  apparent  that  the  diver- 
gent results  obtained  by  various  investigators  were  dependent  chiefly 
upon  three  factors :  ( 1 )  The  standard  set  for  the  tubercle  bacillus — 
whether  the  staining  of  acid  fast  bodies  morphologically  similar  to  the 
tubercle  bacillus  was  to  be  accepted,  or  whether  inoculation,  culture,  or 
histologic  changes  were  to  be  demanded  before  determining  the  exciting 
cause;  (2)  the  different  types  of  cases  from  which  material  was  ob- 
tained— acute  and  chronic;  (3)  errors  in  technic. 

44 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  45 

CONGENITAL  TUBERCULOSIS 

Tuberculosis  was  probably  recognized  many  hundreds  of  years  prior 
to  the  Christian  era  (Williams,5  Osier,6  Waldenburg,7  Predohl 8  and 
Johne9).  Hippocrates  (460-376  B.  C),  Galen  (200-131  B.  C),  and 
Celsus  (30  B.  C.)  described  the  disease,  and  to-day  the  mortality  statistics 
show  that,  of  all  deaths,  from  nine  to  twelve  per  cent  are  due  to  this 
affection  (Rosenau  10).  It  is  not  strange,  therefore,  that  the  etiology  of 
so  ancient  and  wide  spread  a  scourge  as  tuberculosis  should  have  received 
careful  study. 

It  was  early  observed  that  the  children  of  tuberculous  parents  were 
much  more  frequently  attacked  by  the  disease  than  were  the  offspring  of 
healthy  progenitors.  Prior  to  the  discovery  of  the  tubercle  bacillus  by 
Koch  in  1882,  the  theory  that  tuberculosis  was  of  congenital  origin  re- 
ceived much  consideration.  Subsequently,  however,  the  belief  began  to 
lose  ground,  and  the  frequency  with  which  tuberculous  offspring  were 
born  of  infected  parents  was  explained  by  the  doctrine  of  postnatal  in- 
fection, aided,  perhaps,  by  a  hereditary  predisposition.  That  the  major- 
ity of  cases  are  thus  caused  has  been  proved  beyond  doubt.  Recent  in- 
vestigations, however,  by  Schmorl  and  Geipel,3  Novak  and  Ranzel,2 
Sitzenfrey,11  Warthin  and  Cowie,12  and  others  tend  to  show  that  not 
only  does  congenital  tuberculosis  occur,  but  that  it  may  be  relatively 
more  frequent  than  is  generally  assumed. 

Definition. — The  name  "congenital  tuberculosis"  should  be  reserved 
for  those  cases  in  which  tubercle  bacilli  are  present  in  the  fetus  at  or 
prior  to  birth.  A  sharp  discrimination  must  be  made  between  congenital 
infection  and  congenital  predisposition.  Numerous  attempts  have  been 
made  to  classify  infection  of  the  embryo  or  fetus.  Martius  13  has 
strongly  emphasized  the  distinction  between  the  terms  "congenital"  and 
"inherited." 

He  applies  the  term  "congenital"  to  any  condition  that  may  be  present 
in  the  child  at  the  time  of  its  birth,  and  the  term  "inherited"  only  to  that 
condition  which  develops  as  the  direct  result  of  the  conjugation  of  the 
two  sex  cells ;  in  other  words,  anything  that  is  given  to  the  new  organism 
from  the  germinative  plasma.  The  terms  "congenital"  and  "inherited" 
are  somewhat  confusing.  It  would  seem  advisable  to  use  the  term 
"congenital"  to  cover  both  varieties  of  infection,  and,  in  these  cases  in 
which  it  may  be  necessary  to  differentiate  between  the  two  forms,  to 
use  the  term  "germinative"  as  descriptive  of  an  infection  caused  by  the 
spermatozoon  or  ovum — the  germinative  cell — applying  the  denomina- 


46  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

tive  intra-uterine  or  placental  infection  to  those  cases  having  hematog- 
enous or  other  intra-uterine  or  placental  origin. 

Etiology. — Congenital  tuberculous  infection  may  occur  in  a  number 
of  ways ;  it  may  be  due  to  the  spermatozoon  or  the  ovum — the  germina- 
tive  infection;  or  the  products  of  conception  may  subsequently  be  in- 
fected as  the  result  of  a  maternal  bacillemia ;  or  it  may  be  the  result  of  a 
direct  extension  from  surrounding  structures,  either  by  continuity  or 
through  adjacent  lymph  channels. 

Most  authorities  agree  that  tubercle  bacilli  are  present  in  the  blood 
stream  under  certain  conditions,  especially  in  the  acute  miliary  form  of 
the  disease  and  in  the  terminal  stages;  that  they  are  probably  not  con- 
stantly present,  are  frequently  few  in  number,  are  generally  difficult  to 
demonstrate,  and  that  slight  errors  of  technic  may  lead  to  erroneous  con- 
clusions (Rump,58  Liebermeister,59  Giirner,60  Dressen,61  Gobel,62 
Klemperer,63  Kahn,64  Kessler,65  Bacmeister,66  Vinogradoff,67  and 
others).  The  writer  believes,  with  Fraenkel,68  that  the  microscopic  ex- 
amination of  the  blood  for  tubercle  bacilli  is  likely  to  prove  misleading, 
and  that  the  inoculation  of  animals  is  the  only  possible  means  of  arriving 
at  correct  conclusions.  Of  22  persons  examined  by  Fraenkel,  only  two 
gave  positive  results.  Elsasser  69  tested  41  cases  of  advanced  tuberculosis, 
and  was  able  to  demonstrate  the  microorganism  in  J. 2,  per  cent  of  cases. 
Bogason  70  recovered  the  organism  in  only  two  of  41  patients,  although 
he  employed  10  c.cm.  of  blood.  The  work  of  Massel  and  Breton  recently 
reported  by  Calmette  71  is  of  especial  interest  in  this  connection.  These 
investigators  found  that  tuberculosis  could  be  produced  with  relative 
frequency  by  the  direct  transfusion  of  blood  from  a  tuberculous  to  a 
healthy  guinea  pig.  By  this  method  it  was  possible  to  transmit  tuber- 
culosis quite  frequently,  even  from  animals  in  whom  the  disease  was 
chronic  or  the  lesions  comparatively  small. 

Pregnancy  is  prone  to  light  up  a  latent  or  chronic  tuberculosis,  and 
thus  produce  a  condition  in  which  a  bacillemia  is  likely  to  be  present. 
Secondary  infection  and  metastasis  occur  in  the  placenta  in  the  same 
manner  in  which  they  affect  other  portions  of  the  body.  Dardeleben 
goes  so  far  as  to  assert  that  the  placenta  is  the  locus  minoris  resistentiae 
of  the  gravid  woman. 

GERMINATIVE  INFECTION 

Spermatozoic. — Tubercle  bacilli  have  never  been  demonstrated 
within  the  spermatozoon.  In  order  to  produce  infection,  however,  it  is 
not  necessary  for  the  bacilli  to  invade  the  spermatozoa,  for  a  tubercle 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  47 

bacillus  adherent  to  the  outer  surface  of  the  cell  may  effect  a  similar 
result.  A  tubercle  bacillus  may  become  attached  to  a  spermatozoon 
at  any  point  along  its  course — testicle,  vas  deferens,  prostatic  fluid, 
urethra,  external  surface  of  penis,  vulva,  vagina,  cervix,  uterus,  or  even 
the  fallopian  tube.  It  is,  therefore,  theoretically  possible  for  an  ovum 
to  become  infected  by  a  spermatozoon,  the  tubercle  bacillus  having  orig- 
inated in  the  woman  or  been  derived  from  an  exanthropic  source. 

That  spermatozoa  may  be  the  germ  carriers  in  diseases  other  than 
tuberculosis,  has  been  demonstrated  (Bab,14  Sakurane,15  Fouquet,10 
Feuillee,17  and  others),  and  although  the  likelihood  of  such  an  event 
occurring  varies  markedly  in  the  different  diseases,  the  possibility  of 
their  being  the  carriers  of  tuberculous  infection  must  be  considered. 
The  presence  of  organisms  other  than  the  tubercle  bacillus  in  or  at- 
tached to  the  spermatozoon  does  not  always  inhibit  the  activity  of  the 
latter. 

In  considering  the  variety  of  infection,  the  experiments  of  Wald- 
stein  and  Ekler  18  are  of  interest.  These  authors  report  that  in  normal 
rabbits  the  biologic  tests  appeared  to  show  that  in  the  female  organism 
absorption  of  the  spermatic  fluid  occurs.  This  observation  will,  how- 
ever, require  further  verification. 

Tuberculosis  of  the  male  genito-urinary  tract  is  by  no  means  in- 
frequent. Viet 19  and  Martin  20  assert  that  involvement  of  the  genital 
tract  occurs  in  three  per  cent  of  tuberculous  males.  Guiteras  21  reports 
that,  next  to  the  gonorrheal,  the  tuberculous  variety  is  the  most  fre- 
quent form  of  epididymitis.  When  tuberculosis  of  the  genital  or  urinary 
tract  is  present,  the  semen  frequently  contains  tubercle  bacilli;  on  the 
other  hand,  in  some  cases,  notably  in  that  of  D'Aubeau,22  the  discovery 
of  the  tubercle  bacillus  in  the  semen  and  the  absence  of  lesions  in  the 
genito-urinary  tract  were  the  first  evidences  of  the  existence  of  pul- 
monary phthisis.  Jani  23  and  others  have  reported  the  finding  of  tuber- 
cle bacilli  in  the  testes  of  phthisical  men  in  whom  no  demonstrable 
genital  lesions  were  present.  Jani  found  the  bacillus  present  in  5  of  8 
cases  examined.  Sirenae  24  injected  the  semen  from  a  tuberculous  pa- 
tient into  dogs,  which  then  developed  tuberculosis,  Solles  25  and  Foa  26 
report  similar  results.  Spano,27  in  six  cases  of  phthisis,  demonstrated 
the  presence  of  tubercle  bacilli  in  the  seminal  vesicles  in  five.  Jackh  28 
likewise  demonstrated  the  presence  of  tubercle  bacilli  in  the  testicular 
secretion  in  two  cases  of  acute  miliary  tuberculosis.  Somewhat  similar 
results  were  also  obtained  by  Lowenstein.29 

Theoretically,  tubercle  bacilli  free  in  the  blood  should  not  gain  access 
to  the  testicular  or  prostatic  fluid,  but  should  become  enmeshed  in  the 


48    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

fine  capillaries  leading  to  the  glandular  structures  of  the  testes  or  pros- 
tate; Grawitz,30  however,  showed  that  the  mold  germs,  which  have  a 
larger  diameter  than  tubercle  bacilli,  may  under  certain  conditions  reach 
the  testicular  secretion  by  way  of  the  blood  stream.  Murphy  31  calls 
attention  to  the  fact  that  it  is  extremely  difficult,  in  some  cases,  to  make 
a  diagnosis  of  tuberculous  seminal  vesiculitis,  and  that  probably  many 
of  the  cases  in  which  the  genitalia  have  been  considered  normal 
have  in  reality  been  instances  in  which  this  focus  has  been  over- 
looked. 

The  work  of  Rohlff  32  and  Westmayer  33  tends  to  support  Murphy's 
opinion,  in  that  these  investigations  have  demonstrated  that  tubercle  ba- 
cilli are  rarely  present  in  the  semen  of  phthisical  men,  if  genital  lesions 
are  absent.  Rohlff  inoculated  goats  and  rabbits  with  the  spermatic  fluid 
obtained  from  ten  men  who  had  died  of  pulmonary  tuberculosis,  with 
negative  results.  Westmayer  injected  the  ground  up  particles  of  the 
testicles  of  similar  subjects  into  the  peritoneal  cavity  of  rabbits,  with 
like  results. 

Dobroklonski,34  by  means  of  smears  and  inoculations,  tested  the 
semen  of  25  men  who  had  died  of  pulmonary  phthisis.  Twenty-four 
were  negative,  the  one  positive  result  being  obtained  from  a  subject  in 
whom  a  tuberculous  epididymitis  was  present.  Walther 35  examined 
161  sections  made  from  the  testes,  epididymes,  and  prostates  of  12 
phthisical  subjects,  without  finding  a  single  tubercle  bacillus. 

Gartner  36  injected  a  pure  culture  of  tubercle  bacilli  into  the  testes 
of  22  rabbits  and  21  guinea  pigs;  he  then  mated  these  animals  with  65 
females.  In  none  of  the  29  rabbits  or  45  guinea  pigs  which  were  born 
did  tuberculosis  develop,  except  in  one,  the  infection  in  this  case  prob- 
ably being  caused  by  food.  Cornet 37  was  unable  to  demonstrate  the 
presence  of  tuberculosis  either  microscopically  or  by  culture  methods  in 
32  fetuses  and  young  animals  bred  from  guinea  pigs  the  male  parents 
of  which  had  been  inoculated  in  the  testes,  prior  to  breeding.  Numerous 
instances  are  on  record  in  which  fetal  tuberculosis  has  been  produced 
experimentally  in  animals  by  injecting  cultures  of  tubercle  bacilli  into 
the  vagina  just  before  or  immediately  after  coitus  (Friedman,38 
Varaldo,39  and  others).  These  results  are,  however,  valueless,  for  a 
maternal  infection  followed  by  a  hemogenic  infection  of  the  products 
of  conception  was  probably  the  etiologic  factor. 

A  tuberculous  ulceration  of  the  penis  may  also  be  the  means  of 
introducing  tubercle  bacilli  into  the  vagina  with  the  semen.  Cornet 
mentions  the  possibility  of  tubercle  laden  sputum  being  used  as  a  lubri- 
cant during  coitus,  with  resulting  infection.     From  what  has  been  said  it 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  49 

would  seem  fair  to  assume  that  although  germinative  congenital  tuber- 
culosis of  spermatozoic  origin  may  occur,  it  is  extremely  rare. 

Unfertilized  Ovum. — Infection  of  the  ovum  may  take  place  in  the 
ovary,  either  before  or  after  rupture  of  the  graafian  follicle,  in  the  peri- 
toneal cavity,  fallopian  tube,  or  even  in  the  uterus,  although  it  is  generally 
accepted  that  fertilization  of  the  ovum  usually  takes  place  in  the  fallopian 
tube.  As  in  the  spermatozoic  infection,  the  tubercle  bacilli  may  be  either 
in  or  attached  to  the  ovum;  in  the  latter  event  it  may  subsequently  gain 
entrance  with  the  fertilizing  spermatozoon  or  very  shortly  afterward. 
The  deeidua  reflexa  is  probably  formed  almost  immediately  after  the 
entrance  of  the  fertilized  ovum  into  the  uterus,  so  that  the  event  last 
intimated  is  extremely  unlikely. 

Sitzenfrey,11  in  one  case,  found  tubercle  bacilli  situated  in  a  primor- 
dial follicle  of  a  human  ovum.  The  patient  was  eighteen  years  old,  and 
four  years  previously  had  had  a  peritonitis,  presumably  of  tuberculous 
origin.  At  operation  both  adnexa  were  found  to  be  tuberculous.  Schott- 
lander  40  has  produced  tubercles  and  giant  cells  experimentally  within 
developing  graafian  follicles  in  rabbits.  Landouzy  41  believes  that  in  rare 
instances  infection  of  the  ovum  from  a  tuberculous  oophoritis  or  salpin- 
gitis may  occur.  That  intra-ovarian  infection  of  the  ovum  does  take 
place  has  been  definitely  proved,  but  that  extra-ovarian  infection 
occurs  rests  only  upon  a  theoretic  basis.  It  is  doubtful  if  an  ovum  in- 
fected within  the  ovary,  if  fertilized,  could  develop.  Ova  infected  out- 
side the  ovary  would  naturally  possess  a  slightly  greater  chance  of 
developing. 

Ovarian  infection  and  germinal  transmission  of  disease  have  been 
demonstrated  by  Rettger's  42  investigation  of  bacillary  white  diarrhea  in 
the  common  domestic  fowl.  Chicks  which  survive  frequently  become 
permanent  bacillus  carriers,  the  ovary  being  the  important  seat  of  infec- 
tion. The  eggs  from  such  carriers  often  harbor  the  organism  of  the 
disease  in  the  yolk,  and  chicks  from  these  eggs  are  congenitally  infected. 

The  fact  that  when  intra-ovarian  infection  does  occur,  the  fallopian 
tubes  are  usually  involved,  and  are  often  occluded,  may  to  a  certain 
extent  prevent  the  more  frequent  fertilization  of  such  ova.  That  the 
ovum  may  be  infected  by  microorganisms  other  than  the  tubercle  bacillus 
has  been  amply  proved  (Hoffmann  and  Wolters,43  Levaditi  and  Saur- 
age,44  Bab,45  Magalhaes,46  Koch,47  Simmonds,48  and  others). 

Congenital  Germinative  Tuberculosis. — From  what  has  been 
stated  it  may  be  seen  that  germinative  tuberculosis  may  take  place  in 
three  ways  :  ( 1 )  the  tubercle  bacilli  may  enter  the  ovum  with  the  fertiliz- 
ing spermatozoon,  either  attached  to  the  surface  of,  or  actually  within, 


50    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

the  male  germinative  cell;  (2)  the  tubercle  bacilli  may  be  lodged  within 
the  ovum,  which  is  later  fertilized;  (3)  or  the  tubercle  bacilli  may  have 
been  attached  to  either  the  spermatozoon  or  the  ovum  and  gain  access  to 
the  latter  shortly  after  fertilization.  The  question  as  to  whether  an 
infected  fertilized  ovum  would  develop  is  open  to  grave  doubt. 

We  are  willing  to  admit  that,  theoretically,  germinative  infection  may 
occur;  but  viewed  from  a  practical  standpoint,  this  form  of  tuberculous 
infection  is  probably  too  rare  to  be  seriously  considered  as  a  factor  in 
congenital  tuberculosis.  Further  investigation  of  this  subject  is  neces- 
sary, and  a  careful  study  of  the  embryos  and  early  gestation  sacs  of 
tuberculous  parents  would  doubtless  yield  much  information.  The  dem- 
onstration of  a  germinative  infection  is  obviously  extremely  difficult,  and 
most  authors  agree  with  Cornet  that  its  existence  has  not  yet  been  proved. 


PLACENTAL  AND  FETAL  TUBERCULOSIS 

It  is  a  generally  accepted  fact  that  fertilization  of  the  ovum  takes 
place  within  the  fallopian  tube — probably  in  its  outer  portion — and  that 
from  this  point  it  is  carried  along  by  the  action  of  the  cilia  of  the  surface 
tubal  epithelium  to  the  uterine  cavity,  where  it  becomes  implanted.  It  is 
possible,  therefore,  for  tubercle  bacilli  to  enter  the  fertilized  ovum  at 
any  point  along  its  course.  Obviously,  the  uterus  is  the  most  likely  point 
for  infection  to  take  place.  This  may  occur  by  four  different  routes,  ( 1 ) 
hematogenic;  (2)  lymphogenic;  (3)  by  direct  extension  through  con- 
tinuity; and  (4)  by  tubercle  bacilli  gaining  access  from  without. 

Susceptibility  to  Tuberculosis. — It  would  seem  advisable,  at  this 
point,  to  digress  and  to  discuss  briefly  the  action  exercised  by  the  ma- 
ternal toxins  and  antibodies  upon  the  presumably  hitherto  uninfected 
products  of  conception.  This  subject  has  received  much  attention  and 
been  widely  discussed  by  Hollos,49  Rosenau  and  Anderson,50  Huppe,51 
Bartel,52  Klebs,53  and  many  others,  and  the  question  as  to  whether  the 
embryo,  fetus,  or  child  of  a  tuberculous  mother  is  hyposusceptible  or 
hypersusceptible  to  the  action  of  the  tubercle  bacilli  is  still  in  doubt. 
When  we  consider  how  susceptible  the  fetus  is  to  the  maternal  tuber- 
culous toxins,  it  would  seem  that  the  general  nutrition  must  become 
impaired. 

Carriere  54  showed  experimentally  that  in  animals  tuberculous  toxins 
influenced  pregnancy  by  reducing  the  number  of  the  offspring,  and  that 
in  many  instances  these  died  in  utcro  or  shortly  after  birth,  or  that  those 
that  survived  were  weak.     The  effects  were  most  marked  when  toxins 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  51 

from  both  parents  were  injected.  This  investigator  believed  that  the 
surviving  young  animals  were  more  susceptible  to  tuberculous  infection 
than  were  the  control  animals.  Ballantyne  states  that,  once  the  tubercle 
bacilli  have  gained  access  to  the  fetal  tissues,  they  find  there  an  excellent 
soil  for  development.  Pankow  4  inoculated  a  number  of  guinea  pigs 
with  portions  of  placentas  obtained  from  twenty  cases  of  suspected  or 
congenital  tuberculosis.  Three  of  these  pigs  died  within  a  few  days, 
presumably  from  a  toxemia,  for  in  none  of  them  was  it  possible  to  dem- 
onstrate the  presence  of  tubercle  bacilli. 

Bossi 55  injected  the  ground  up  particles  of  placentas  of  tuberculous 
women  into  guinea  pigs,  and  found  that  marked  evidences  of  toxemia 
resulted.  The  effects  were  more  lethal  when  placentas  from  women  far 
advanced  in  tuberculosis  or  in  poor  general  health  were  used,  and  in 
those  from  patients  who  showed  large  numbers  of  tubercle  bacilli  in  the 
sputum.  Control  experiments  with  eight  placentas  coming  from  healthy 
women  gave  negative  results.  Bossi,  therefore,  concludes  that  there  are 
in  the  placenta  of  tuberculous  women  toxins  that  are  transmitted  to  the 
fetus  and  that  may  cause  death  or  miscarriage,  or  result  in  the  birth  of 
weaklings.  Cornet's  37  views  agree  with  those  of  Bossi,  and  he  believes 
that  the  toxins  result  from  a  process  of  osmosis.  He  does  not,  however, 
consider  that  such  toxins  increase  the  susceptibility  to  tuberculosis,  but, 
on  the  contrary,  he  believes  that  the  fetus  in  utero  acquires  a  certain 
amount  of  immunity.  With  this  latter  view,  Sitzenfrey,11  Hollos,49 
Warthin,12  and  the  author  are  in  accord. 12a  Many  excellent  observers, 
however,  hold  a  contrary  opinion.  Pehu  and  Charlier  56  believe  that  the 
offspring  of  tuberculous  parents  are  prone  to  defective  development. 
They  think  that  these  children  undoubtedly  present  a  receptive  soil  for 
all  diseases,  but  not  especially  to  tuberculosis. 

Undoubtedly,  many  cases  have  been  recorded  in  which  tubercle  bacilli 
were  positively  demonstrated  in  large  numbers  in  the  fetus  or  new  born 
child,  no  other  pathologic  changes  being  present — a  finding  that  requires 
further  study. 

Tuberculous  Bacillemia. — The  frequency  with  which  tubercle 
bacilli  occur  in  the  blood  stream  in  infected  individuals  is  a  somewhat 
disputed  point. 

The  Histology  and  Physiology  of  the  Placenta  in  Relation  to 
the  Routes  of  Transmission  of  the  Tubercle  Bacilli. — For  a  thorough 
understanding  of  placental  and  congenital  tuberculosis  a  knowledge  of 
the  pathological  processes  that  occur  in  these  conditions  is  necessary.  An 
important  point  that  immediately  presents  itself  to  the  investigator  is 
whether  or  not  the  transmission  of  the  tubercle  bacilli  occurs  through  the 


52  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

normal  placenta.  A  number  of  cases  are  on  record  in  which  congenital 
tuberculosis  has  been  observed  in  the  child  and  no  histologic  changes  were 
detected  in  the  placenta.  Even  more  numerous  are  the  cases  in  which 
tubercle  bacilli  were  demonstrated  in  the  placenta,  or  fetus  and  placenta, 
and  in  which  no  histologic  changes  were  found.  In  accepting  these  cases 
as  genuine,  care  must  be  observed,  as  the  demonstration  of  tubercle 
bacilli  in  the  blood,  either  by  staining  methods  or  by  animal  inoculation, 
is  not  reliable  unless  a  strict  technic  is  adhered  to.  It  must  also  be 
remembered  that,  in  order  positively  to  prove  that  the  placenta  in  a  given 
case  was  normal,  the  entire  structure  must  be  subjected  to  serial  section. 
So  far  as  can  be  ascertained,  this  stupendous  task  has  never  been  at- 
tempted, and  even  if  it  were,  the  possibility  that  healing  might  have 
occurred  in  the  placenta  after  the  tubercle  bacilli  were  transmitted  could 
not  be  entirely  excluded.  Warthin  and  others  have  described  the  healing 
of  tuberculous  lesions  in  the  placenta. 

The  placental  transmission  of  syphilis,  leprosy,  variola,  anthrax, 
pneumonia,  and  recurrent  fevers  has  been  positively  demonstrated  in 
man  (Lubarsch,72  Schaudinn,73  Paschen,74  Wallich  and  Levaditi,75 
Menetrier  and  Rubeno-Duval,76  Neuhaus,77  Freund  and  Levy,78  Van 
der  Wittigen,79  Dorland,80  Runge,81  Nattan-Larrier  and  Brindeau,82 
Delestre,83  Bar' and  Renon,84  and  others). 

Preyer,85  Savory,86  Fournier,87  and  others  have  demonstrated  that 
toxins  injected  into  the  mother  may  produce  the  death  of  the  fetus.  As 
early  as  1877,  Zweifel 88  showed  that  chloroform  administered  to  the 
mother  also  affected  the  fetus,  and  more  recently  the  work  of  Jung  89  has 
shown  the  passage  of  certain  drugs  through  the  placenta. 

Under  normal  circumstances  the  blood  in  the  intervillous  spaces  is 
entirely  maternal  in  origin  (Waldeyer,90  Bumm,91  Leopold,92  etc.),  as 
the  fetal  blood  at  no  time  gains  direct  access  to  the  intervillous  spaces, 
the  two  blood  supplies  being  separated  from  each  other  by  the  vessel  wall 
and  the  two  layers  of  chorionic  epithelium.  During  the  latter  stages  of 
pregnancy  Langhans'  layer  is,  however,  absent.  It  seems  probable  that, 
when  material  is  transmitted  through  the  placenta,  the  process  is  effected 
partly  by  osmosis  and  partly  by  the  direct  action  of  the  syncytial  cells, 
the  physiology  of  the  latter  being  somewhat  analogous  to  that  of  the 
renal  tubules.  Williams,93  and  Cornet  37  are  of  the  opinion  that  when 
the  placenta  is  normal  and  the  epithelium  covering  the  villi  is  intact, 
transmission  of  the  disease  germs  cannot  occur,  but  that  when  lesions  of 
the  placenta  are  present,  transmission  may  take  place.  It  remains  to  be 
decided,  however,  whether  the  lesions  that  have  been  demonstrated  in 
some  cases  of  tuberculosis  have  antedated  the  disease,  or  whether  thev 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  53 

have  been  the  result  of  tuberculous  toxins  produced  by  the  bacteria  in  the 
intervillous  blood.  Delore  94  is  of  the  opinion  that  the  disorganization 
of  the  syncytium  is  not  the  result  of  toxins  or  of  inflammation,  but  is 
due  to  a  myxomatous  degeneration.  Warthin  95  believes  that  the  syncy- 
tium of  the  chorionic  villi  is  no  more  immune  to  the  action  of  the  tubercle 
bacilli  than  is  the  vascular  endothelium  in  other  parts  of  the  body,  and 
that  the  theory  that  tubercle  bacilli  can  pass  through  this  layer  of  cells 
without  causing  injury  to  it  is  founded  on  fact.  Sitzenfrey  ll  is  of  a 
similar  opinion.  In  this  connection  it  should  be  stated  that  the  inter- 
villous spaces  are  not  lined  by  endothelium,  except  for  a  short  distance 
on  the  surface  of  the  decidua  basalis,  into  which  the  endothelium  of  the 
maternal  vessels  extends.  The  author  is  of  the  opinion  that  tubercle 
bacilli  may  be  transmitted  through  the  normal  placenta.  This  opinion  is 
based  upon  the  fact  that  a  number  of  cases  are  on  record  in  which  un- 
doubted congenital  tuberculosis  has  been  present  and  a  careful  examina- 
tion of  the  placenta  has  failed  to  show  histologic  lesions  in  the  same. 

In  the  case  of  tuberculosis,  at  least,  this  question  is  perhaps  of  more 
theoretic  than  of  practical  value.  It  is  probable  that  the  toxins,  the  result 
of  enmeshed  tubercle  bacilli,  may  produce  injury  to  the  syncytium,  and 
thus  by  the  damage  incurred,  prepare  the  way  for  the  entrance  of  tubercle 
bacilli.  Furthermore,  in  the  latter  months  of  pregnancy,  infarcts  are 
frequently  present,  and  doubtless  constitute  foci  by  which  ingress  is 
secured  for  the  organisms  in  the  intervillous  spaces. 

Williams  describes  five  varieties  of  infarcts.  All  placentas  contain 
small  infarcts,  and  Williams  states  that  these  attain  a  diameter  of  one 
centimeter  or  more  in  63  per  cent  of  cases.  Owing  to  the  histologic 
structure  of  the  decidua  basalis  and  placenta,  these  structures  offer  espe- 
cial facilities  for  the  enmeshing  of  microorganisms  circulating  in  the 
maternal  blood  stream,  a  point  that  has  recently  been  emphasized  by 
Warnekros,96 

It  is  probable  that,  in  the  majority  of  cases  in  which  congenital  infec- 
tion occurs,  the  tubercle  bacilli  travel  through  the  decidual  arteries  to  the 
covering  of  the  villi  and  there  accumulate,  causing  thrombi  in  their  own 
and  in  adjacent  intervillous  spaces,  with  subsequent  destruction  of  the 
syncytial  cells,  enter  the  villous  stroma,  and  finally  reach  the  chorion.  To 
what  extent  this  process  is  aided  by  the  action  of  the  toxins  is  not 
definitely  known,  but  it  would  seem  probable  that  they  act  as  predispos- 
ing factors  and  tend  to  weaken  or  even  destroy  the  intervening  layers  of 
cells. 

Schmorl  and  Kockel,97  in  their  carefully  prepared  report  of  the  path- 
ology of  placental  tuberculosis,  state  that  placental  villi,  even  when  en- 


54  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

tirely  embedded  in  the  tuberculous  areas,  tend  to  retain  their  integrity 
and  are  easily  differentiated  from  the  surrounding  tissue.  "Even  the 
identical  villus  on  which  the  primary  localization  of  the  tubercle  bacilli 
occurred,  and  which,  in  consequence,  lacks  its  cellular  sheath  in  places, 
remains  for  a  long  time  unchanged.  The  tubercle  bacilli  may  be  very 
plentiful  in  the  tuberculous  new  growth,  yet  within  the  villi  surrounding 
this  area  we  find  but  few."  These  authors  further  declare  that,  even  if 
the  villus  becomes  tuberculous,  a  thrombosis  and  partial  obstruction  to 
the  vessel  occur,  which  may  entirely  or  in  part  prevent  the  passage  of 
the  bacillus. 

As  has  previously  been  stated,  the  infarcts  that  are  so  frequent  in 
the  latter  months  of  pregnancy  also  probably  serve  in  some  instances  as 
channels  for  the  invading  microorganisms.  The  virulence  of  the  infect- 
ing agent  and  the  resistant  power  of  the  host  are  also  probably  important 
factors  in  the  production  of  the  disease.  It  is  a  significant  fact  that  a 
large  proportion  of  the  reported  cases  of  congenital  tuberculosis  have 
occurred  in  conjunction  with  the  acute  miliary  variety  of  the  disease. 

Undoubtedly  the  strong  uterine  contractions  incident  to  labor  con- 
stitute a  most  important  factor  in  the  transmission  of  tubercle  bacilli  at 
the  end  of  pregnancy.  Organisms  that,  prior  to  the  onset  of  labor,  were 
lodged  in  the  placenta  or  in  the  intervillous  spaces,  may,  as  the  result  of 
these  contractions,  be  forced  into  the  fetal  circulation.  Schlimpert,1 
Schmorl  and  Geipel,3  Warthin  and  Cowie,12  Dardeleben,  and  others  are 
very  insistent  on  this  point.  Tubercle  bacilli  are  relatively  frequently 
transmitted  through  macroscopically  normal  placentas,  and  may  possibly 
pass  through  histologically  normal  organs,  although  positive  proof  of 
the  latter  is  lacking. 

In  addition  to  the  hematogenous  infection,  tubercle  bacilli  may  reach 
the  decidua  by  direct  extension  from  the  fallopian  tubes  or  cervix,  and 
thence,  by  continuity,  pass  into  the  placenta.  A  lymphatic  infection  from 
an  adjacent  tuberculous  lesion  may  also  occur.  In  either  of  these  ways 
a  focus  of  infection  is  set  up  in  the  decidua,  and  may  extend  to  the 
chorion,  thus  reaching  the  body  of  the  fetus,  and  infecting  it  through  the 
respiratory  tract,  the  result  of  inspiration  of  the  amniotic  fluid,  through 
the  gastro-intestinal  tract,  or  through  the  skin.  Asch  98  and  numerous 
other  observers  have  recorded  instances  of  supposed  intra-uterine  suck- 
ing, and  even  in  adults,  whose  dermis  should  be  more  resistant  than  that 
of  the  fetus,  infection  without  macroscopic  loss  of  continuity  has  occa- 
sionally been  observed  (by  Leloir,"  Baginsky,100  and  experimentally  by 
Wasmuth,101  Roth,102  and  others).  In  a  case  described  by  Schmorl  and 
Geipel  3  a  tuberculous  area  in  the  chorion  had  penetrated  the  amnion, 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  55 

and  tubercle  bacilli  were  found  on  the  surface  of  the  membrane.  Herr- 
gott 103  inoculated  guinea  pigs  with  the  amniotic  fluid  of  a  tuberculous 
woman  who  died  in  the  sixth  month  of  pregnancy.  The  animals  devel- 
oped tuberculosis,  showing  that,  in  this  case,  the  amniotic  fluid  contained 
virulent  tubercle  bacilli. 

Aside  from  the  infarcts  previously  mentioned  and  the  fact  that  high 
fever  is  likely  to  produce  a  loss  of  continuity  of  the  maternal  and  fetal 
blood  vessels  and  thus  favor  transmission  of  the  bacillus,  disease  of  the 
placenta  other  than  tuberculosis  may  produce  lesions  that  will  facilitate 
the  occurrence  of  a  congenital  infection  by  opening  up  avenues  for  the 
entrance  of  tubercle  bacilli.  This  is  particularly  the  case  in  syphilis,  of 
which  Hochsinger's  104  case  is  an  example.  Trauma  may  also  serve  as  a 
predisposing  factor  in  the  transmission  of  the  bacillus  through  the 
placenta. 

In  examining  specimens  of  suspected  congenital  tuberculosis,  the 
greatest  care  must  be  observed  to  exclude  cases  of  possible  extra-uterine 
infection.  As  pointed  out  by  Virchow,  syphilis  may  closely  simulate 
tuberculosis.  Henle  105  described  a  case  of  pseudotuberculosis  in  new 
born  twins. 

It  must  be  remembered  that  placental  tuberculosis  does  not  necessarily 
imply  a  transmission  of  the  infecting  organism  to  the  fetus,  although,  of 
course,  the  condition  strongly  favors  congenital  tuberculosis,  for,  if 
advanced,  it  must  produce  lesions  that  facilitate  the  passage  of  the  bacilli 
through  the  placenta. 

Frequency  of  Congenital  Tuberculosis. — Tuberculosis  is  the  most 
frequent  serious  infectious  disease  that  attacks  mankind.  It  has  been 
estimated  that  from  9  to  12  per  cent  of  all  deaths  are  due  to  tuberculosis. 
In  Germany,  during  one  year,  the  mortality  statistics  show  that  diph- 
theria, pertussis,  scarlatina,  rubeola,  and  typhoid  fever  were  accountable 
for  116,705  deaths,  whereas  during  a  similar  period  tuberculosis  was 
responsible  for  123,904  deaths. 

Genital  tuberculosis  is  by  no  means  an  uncommon  affection.  Genital 
lesions  are  predisposing  factors  to  congenital  tuberculosis,  especially  if 
the  fallopian  tubes  are  patulous.  The  frequency  of  this  form  of  infection 
is,  therefore,  of  especial  interest.  In  the  gynecological  laboratory  of  the 
University  of  Pennsylvania  it  has  been  found  that  seven  per  cent  of 
all  cases  of  pelvic  inflammatory  diseases  are  of  tuberculous  origin. 
Williams  5  states  that  eight  per  cent  of  all  cases  of  adnexitis  are  tuber- 
culous. Merlitti 106  places  the  proportion  at  12.6  per  cent.  The  reports 
from  the  University  laboratory  and  from  Williams  are  based  upon  operat 
tive  material,  and  are  of  especial  value,  as  in  both  clinics  all  specimens 


56         GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

are  subjected  to  a  routine  histologic  examination.  Martin 20  found 
twenty-four  tuberculous  cases  among  1 ,600  gynecologic  specimens.  Bark- 
ley,107  in  789  autopsies  performed  upon  women  dead  of  tuberculosis, 
found  the  genital  tract  involved  in  7.7  per  cent.  In  174  cases  of  similar 
material  from  the  Henry  Phipps  Institute,  examined  by  the  writer,  6.6 
per  cent  showed  macroscopic  involvement  of  the  genitalia. 

In  studying  the  frequency  of  congenital  tuberculosis  a  number  of 
points  must  be  considered.  The  great  prevalence  of  tuberculosis  and  the 
comparatively  small  number  of  authentic  cases  of  congenital  infection 
that  are  recorded  are  conclusive  proof,  it  would  seem,  of  the  rarity  of 
the  variety  of  the  disease  in  question.  On  the  other  hand,  it  should  be 
remembered  that  tuberculosis  of  the  placenta  does  not  by  any  means 
always  present  macroscopic  lesions.  There  is,  moreover,  probably  no 
branch  of  pathology  that  has  received  less  attention  than  the  histologic 
study  of  the  placenta.  Baumgarten's  theory,  although  doubtless  extreme 
in  some  respects,  has  done  much  to  show  that  congenital  tuberculosis 
may  occur,  and  that  tubercle  bacilli  may  remain  latent  in  the  child  for 
quite  prolonged  periods.  It  has  been  shown  that  the  tubercle  bacillus  may 
remain  latent  for  some  time.  Under  such  circumstances  congenital  tuber- 
culosis is  probably  mistaken  for,  and  classified  as,  a  postnatal  infection. 
The  transmission,  through  the  human  placenta,  of  microorganisms  of 
other  diseases  is  a  point  tending  to  show  that  congenital  tuberculosis  may 
be  more  frequent  than  is  generally  supposed. 

Until  comparatively  recently  it  was  the  general  belief  that  congenital 
tuberculosis  rarely,  if  ever,  occurred,  and  for  this  reason  but  few  pla- 
centas were  examined  in  order  to  determine  its  existence.  As  has  been 
stated,  even  a  negative  histologic  examination  does  not  by  any  means 
exclude  the  presence  of  tubercle  bacilli  in  the  placenta,  and  it  is  only  by 
routine  histologic  and  bacteriologic  examinations  of  a  large  series  of 
placentas  and  other  products  of  conception  from  tuberculous  women  that 
reliable  conclusions  can  be  reached  regarding  the  frequency  of  placental 
and  congenital  tuberculosis.  Owing,  probably,  to  the  difficulties  of  secur- 
ing such  material,  a  sufficiently  large  number  of  such  examinations  have 
not  been  made.  Sitzenfrey's  X1  series  of  26  cases  is  the  largest  found  in 
the  literature.  When  such  studies  have  been  carefully  carried  out,  the 
results  have  almost  invariably  shown  that  the  presence  of  tubercle  bacilli 
in  the  placenta  is  by  no  means  infrequent.  It  is  a  significant  fact  that 
recent  investigators  have  found  both  congenital  and  placental  tuberculosis 
much  more  frequent  than  did  those  of  the  previous  decade,  the  result, 
probably,  of  the  more  thorough  methods  of  study  now  employed. 

Bossi 55  failed  to  find  tubercle  bacilli  in  any  of  the  placentas  exam- 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  57 

ined  by  him.  Pankow,4  in  a  series  of  20  placentas  from  tuberculous 
women,  was  unable  to  demonstrate  tuberculosis  in  a  single  case.  Despite 
this  fact,  however,  this  investigator  believes  that  placental  and  congenital 
tuberculosis  are  not  rare.  Schmorl  and  Geipel,3  on  the  other  hand,  found 
eight  cases  (40  per  cent)  of  tubercle  bacilli  in  the  placenta  in  a  series  of 
20  tuberculous  women.  Schlimpert x  found  tubercle  bacilli  in  the  pla- 
centa in  eight  of  eleven  cases.  Sitzenfrey,  in  a  series  of  26  cases,  found 
the  organism  in  seven,  and  recovered  the  infecting  bacilli  twice  from  the 
fetal  blood. 

Novak  and  Ranzel 2  examined  the  placentas  from  ten  cases  of 
advanced  pulmonary  tuberculosis.  The  placentas  were  minced,  washed 
in  sterile  water,  digested  in  soda  solution  and  pancreatin,  and  then  mixed 
with  40  per  cent  antiformin  solution.  The  sediment  was  again  washed 
in  alcohol,  stained,  and  examined  for  tubercle  bacilli.  A  histologic  exam- 
ination of  the  placentas  was  also  made,  and  inoculation  of  guinea  pigs 
was  likewise  carried  out  in  many  cases.  As  a  result,  these  authors  found 
positive  evidence  of  tuberculosis  in  seven  of  the  ten  specimens  examined. 
They  regard  the  negative  findings  of  other  observers,  especially  those  of 
Bossi  55  and  Ascoli,108  as  due  to  faulty  technic ;  or  that,  probably,  as  in 
some  cases,  the  specimens  were  obtained  from  early  pregnancies,  in 
which  case  the  infection  would  most  likely  be  limited  to  the  decidua.  A 
summary  of  the  cases  of  Schmorl  and  Geipel,  Novak  and  Ranzel,  Schlim- 
pert, and  Sitzenfrey  shows  that  of  67  cases  examined  30  per  cent  pre- 
sented positive  evidence  of  tubercle  bacilli  in  the  placenta,  of  placental 
tuberculosis,  or  congenital  tuberculosis. 

Many  of  the  earlier  results  secured  regarding  the  demonstration  of 
congenital  or  placental  tuberculosis  are  open  to  criticism  because  of 
the  methods  employed.  Von  Leyden  109  inoculated  animals  with  por- 
tions of  the  liver,  spleen,  and  lungs  of  a  child  born  of  a  tuberculous 
mother,  with  negative  results.  Jaquet 110  was  unable  to  find  tubercle 
bacilli  microscopically  in  several  human  fetuses  of  tuberculous  mothers. 
Vignal 1X1  inoculated  portions  of  the  livers  and  spleens  of  eleven  human 
fetuses  of  tuberculous  mothers  into  guinea  pigs,  with  negative  results. 
Treisser  112  performed  similar  experiments  with  the  livers  and  lungs  of 
three  still  born  infants  of  tuberculous  mothers,  with  similar  results. 

Bernard,  Debrer,  and  Baron,113  in  a  series  of  36  cases  of  advanced 
tuberculosis,  found  the  placenta  involved  in  12.5  per  cent.  Bar  and 
Renon  114  found  tubercle  bacilli  in  the  blood  from  the  umbilical  cord  in 
two  of  five  cases  in  which  the  mothers  were  tuberculous.  It  should  be 
stated,  however,  that  one,  at  least,  of  Bar  and  Renon's  cases  was  not 
above  suspicion. 


58  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Armann  115  regards  tuberculosis  in  infants  as  not  infrequently  of 
congenital  origin.  As  a  general  rule,  in  hematogenous  infections  tubercle 
bacilli  attack  the  lymphatic  glands  nearest  their  point  of  entry.  In  con- 
genital tuberculosis,  therefore,  the  liver,  being  the  inlet  for  the  placental 
blood,  the  lymphatic  glands  in  this  region  would  exhibit  the  first  changes, 
and  this  is  frequently  the  case.  That  the  liver  possesses  some  bacter- 
icidal properties  should,  however,  be  taken  into  consideration.  In  those 
infants  in  whom  the  liver  is  the  organ  chiefly  involved,  this  fact  is  at 
least  suggestive  of  congenital  tuberculosis.  Leroux,116  in  214  autopsies 
performed  upon  tuberculous  infants,  found  the  liver  affected  in  eighty- 
two.  Lannelongue,117  in  1,005  cases  of  surgical  tuberculosis  occurring 
in  young  children  and  infants,  observed  three  that  he  considered  of  con- 
genital origin.  Muller,118  in  150  autopsies  performed  on  tuberculous 
children,  found  the  liver  involved  in  33.3  per  cent  of  cases.  Haupt 119 
was  able  to  demonstrate  that,  of  617  of  his  tuberculous  patients,  143  had 
tuberculous  mothers. 

In  1834  Hardy  120  reported  the  history  of  a  case  of  tuberculosis  of  the 
uterus  and  placenta  occurring  in  a  phthisical  woman.  The  report  is, 
however,  somewhat  vague,  and  in  view  of  the  general  ill  defined  knowl- 
edge of  the  pathology  of  tuberculosis  at  that  period,  this  case  must  be 
regarded  with  doubt.  The  cases  of  Charrin  121  and  Jacobi 122  are,  for 
similar  reasons,  also  open  to  suspicion. 

Until  1 89 1  no  undoubted  case  of  congenital  tuberculosis  had  been 
recorded.  During  that  year  two  cases  were  reported — one  by  Sabou- 
raud  123  and  one  by  Schmorl  and  Birch-Hirschfeld.124  The  latter  authors 
were  the  first  positively  to  demonstrate  the  presence  of  tubercle  bacilli 
in  the  human  placenta. 

Runge  125  regards  his  case  as  the  first  in  which  tubercle  bacilli  were 
positively  identified  in  the  decidua.  As  usual,  no  giant  cells  were  found, 
but  numerous  tubercle  bacilli  were  present,  chiefly  in  the  decidua  basalis. 
Johne  9  was  perhaps  the  first  to  report  the  history  of  an  undoubted  case 
of  congenital  tuberculosis,  his  specimen  consisting  of  an  unborn  calf. 
Macroscopically,  the  uterus  and  placenta  were  normal.  Since  the  pub- 
lication of  Johne's  case,  many  instances  of  congenital  tuberculosis  in 
animals  have  been  recorded.  As  early  as  1897  Klepp  126  reported  that 
he  found  numerous  calves  affected  with  this  form  of  the  disease,  and 
stated  that  2.63  per  cent  of  all  young  born  of  tuberculous  cows  were 
infected  in  titer 0.  Cases  of  congenital  tuberculosis  in  cattle  have  been 
reported  by  Malrox  and  Brouwier 127  (2  cases),  Czoker,128  Bank129 
(3  cases),  McFayden,130  Siegen  131  (38  cases),  Lungwitz  132  (2  cases), 
Nocard,133     Grancher,134     Kohler,135     Misselwitz,136     Bayersdorfer,137 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  59 

Becker,138  Ruser,139  Barland,140  Galtier,141  Bucher,142  and  Lohoff.143 
The  recent  carefully  prepared  report  of  Brooks  144  tends  to  show  that 
the  frequency  of  congenital  tuberculosis  in  cattle  has  been  exaggerated. 
Of  200  calves  born  of  tuberculous  parents,  all  of  which  were  imme- 
diately after  birth  removed  from  the  mother  and  guarded  from  postnatal 
infection,  not  one  became  tuberculous. 


EFFORTS  TO  PRODUCE  CONGENITAL  TUBERCULOSIS 

Animal  Experiments. — Gartner,36  in  an  extensive  series  of  experi- 
ments upon  white  mice,  succeeded  in  producing  congenital  tuberculosis 
in  from  five  to  ten  per  cent  of  cases.  This  was  effected  by  making  intra- 
peritoneal, intravenous,  or  intratracheal  inoculations.  Of  nineteen  litters 
in  which  the  mothers  were  subjected  to  intraperitoneal  injection  of  0.00 1 
to  0.002  c.cm.  of  a  pure  culture  of  tubercle  bacilli,  in  two  cases  the  young 
became  infected.  In  an  attempt  to  simulate  miliary  tuberculosis  (bacil- 
lemia)  this  investigator  injected  0.5  to  2  c.cm.  of  a  pure  culture  of 
tubercle  bacilli  into  the  vein  of  the  ear  of  ten  healthy  rabbits.  Of  fifty- 
one  fetuses  of  young  born  to  these  animals,  five  (10  per  cent)  were 
tuberculous.  In  no  case  were  all  the  young  of  a  litter  infected.  The 
method  of  determining  whether  or  not  infection  was  present  in  the 
young  was  extremely  thorough;  it  consisted  of  grinding  the  young  or 
fetuses  to  a  pulp  and  inoculating  this  into  the  peritoneal  cavities  of  guinea 
pigs.  For  the  purpose  of  producing  conditions  analogous  to  pulmonary 
tuberculosis,  Gartner  injected  a  drop  of  a  pure  culture  of  tubercle  bacilli 
into  the  trachea  of  each  of  sixty-four  mice;  eighteen  litters,  consisting 
of  seventy-four  young,  resulted.  These  were  inoculated  into  39  guinea 
pigs,  and  tuberculous  young  were  found  in  80  per  cent  of  the  litters. 
Another  similar  series  of  experiments  performed  at  a  later  date  upon 
twenty-eight  subjects  showed  only  one  infected  young  animal.  Lan- 
douzy  41  and  Lodenih  145  performed  a  similar  series  of  experiments,  two 
of  the  eighty-six  young  animals  which  resulted  showing  congenital 
tuberculosis.  Numerous  other  investigators  have,  however,  failed  to 
produce  congenital  tuberculosis.  Sanchez-Toledo 146  performed  intra- 
venous infection  on  fifteen  guinea  pigs,  and  in  none  of  the  twenty-five 
fetuses  from  these  animals  was  tuberculosis  present.  Similar  results 
were  secured  by  intrathoracic  inoculation. 

A  summary  of  Sanchez-Toledo's  results  show  that  no  tuberculosis  was 
demonstrated  in  sixty-five  fetuses  from  thirty-two  tuberculous  mothers. 
Cornet,37  in  an  extensive  series  of  experiments,  was  unable  to  produce 


60         GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

congenital  tuberculosis.  Of  233  fetuses  or  young  examined,  not  one 
was  tuberculous.  Von  Nocard  147  inoculated  thirty-two  fetuses  of  four 
tuberculous  rabbits  into  thirty-two  guinea  pigs,  with  negative  results. 
Wolff  148  performed  a  similar  test,  employing  forty-two  fetuses  of  rabbits 
and  guinea  pigs,  with  one  positive  result.  Galtier 141  was  unable  to 
demonstrate  tuberculosis  in  nine  young  from  tuberculous  guinea  pigs 
and  in  one  calf  from  a  tuberculous  cow.  Grancher  134  and  Straus149 
obtained  similar  results  from  the  inoculation  of  suspected  organs  of 
fetuses  from  nine  tuberculous  female  guinea  pigs ;  fourteen  of  the  progeny 
were  inoculated  at  birth,  with  negative  results,  and  the  remainder  were 
examined  at  varying  periods  up  to  sixteen  months  of  age.  Tuberculosis 
could  not  be  demonstrated.  Vignal 11X  performed  similar  experiments 
with  eleven  guinea  pig  fetuses  from  tuberculous  mothers,  with  negative 
results.  Carajnis,150  by  inoculating  the  spleen  of  a  fetus  from  a  tubercu- 
lous guinea  pig,  secured  a  positive  result.  From  the  findings  just 
recorded,  it  can  well  be  seen  that  congenital  tuberculosis  is  difficult  to 
produce  experimentally. 

In  studying  congenital  tuberculosis,  a  sharp  distinction  must  be 
made  between  placental  infection  and  fetal  involvement.  It  by  no  means 
follows  that,  because  a  placental  infection  exists,  the  child  is  necessarily 
contaminated. 

Criticism  and  Possible  Sources  of  Error. — Attention  has  else- 
where been  directed  to  the  small  number  of  cases  of  congenital  or  of 
placental  tuberculosis  in  man  that  have  been  reported,  and  possible 
reasons  for  this  have  been  advanced.  A  review  of  the  literature  since 
1 89 1  shows  that  much  work  has  been  done  on  this  subject,  and  that 
the  opinion  of  most  observers  is  strongly  opposed  to  the  view  that  holds 
the  condition  to  be  frequent.  On  the  other  hand,  a  careful  study  shows 
that  in  most  of  the  investigations  in  which  a  moderately  large  number  of 
specimens  were  examined  and  thorough  methods  of  research  employed, 
a  definite  proportion  of  positive  cases  was  demonstrated. 

The  microscopic  demonstration  of  tubercle  bacilli  alone  in  smear 
preparations  is  in  some  cases  to  be  looked  on  with  suspicion,  as  the 
differentiation  of  other  acid  fast  bodies  must  be  carefully  considered — a 
point  that  should  be  emphasized,  I  believe  with  Fraenkel  and  others, 
that  the  microscopic  demonstration  in  smear  preparations  of  blood  is 
likely  to  be  misleading.  Slight  errors  in  technic,  or  the  presence  of 
acid  fast  bodies  other  than  tubercle  bacilli,  are  prone  to  produce  very 
erroneous  results.  The  findings  of  Novak  and  Ranzel,2  which  have 
previously  been  quoted,  and  whose  experiments  were  evidently  carefully 
carried  out,  may  be  placed  partly  in  this  category. 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  61 

Sitzenfrey  X1  has  very  properly  sounded  a  note  of  warning  against 
accepting  even  inoculation  results,  unless  the  technic  has  been  carefully 
safeguarded.  The  frequency  of  tuberculosis  among  laboratory  animals, 
and  the  possibility  that  incipient  tuberculosis  may  have  been  present 
before  the  inoculation  was  made;  the  possibility  of  contamination  during, 
prior,  or  subsequent  to  the  inoculation,  and  the  marked  susceptibility 
of  guinea  pigs  to  this  form  of  infection,  are  all  sources  of  possible  error. 
Feyerabend  151  has  even  mentioned  the  possibility  of  spontaneous  tuber- 
culosis occurring  in  guinea  pigs.  Even  the  histologic  examination  is 
open  to  misinterpretation.  The  similarity  of  the  picture  produced  by 
certain  forms  of  syphilis  and  other  conditions  to  that  of  tuberculosis 
has  previously  been  pointed  out. 

Experimentally  produced  congenital  tuberculosis  in  animals  is  like- 
wise not  beyond  criticism.  The  relatively  large  amounts  of  culture 
material  inoculated  usually  far  exceed  what  could  possibly  be  present  in 
the  pregnant  woman.  Thus  Gartner,36  whose  results  are  perhaps  more 
convincing  than  those  of  any  other  investigator,  employed  quantities 
of  culture  which,  if  increased  proportionately  to  the  weight  of  an 
average  woman,  would  amount  to  350  gm.  introduced  into  the  trachea, 
35  to  140  gm.  into  the  circulation,  and  about  0.5  to  1.5  liters  into  the 
peritoneal  cavity.  These  results  show,  therefore,  that  while  congenital 
tuberculosis  may  be  produced  experimentally  in  certain  animals,  it  should 
not  be  compared  to  what  takes  place  in  the  tuberculous  pregnant  woman. 

Period  at  which  Intra-uterine  Transmission  is  Most  Likely  to 
Occur. — Placental  tuberculosis  is  undoubtedly  most  frequent  in  the 
latter  months  of  pregnancy.  As  gestation  progresses  the  maternal  focus 
in  the  lungs  or  elsewhere  is  especially  prone  to  exacerbations,  and,  as 
a  result,  organisms  are  more  likely  to  be  present  in  the  maternal  blood 
stream.  Furthermore,  hyperpyrexia  tends  to  produce  a  solution  of  con- 
tinuity of  the  fetal  and  maternal  blood  vessels.  Not  only  is  a  bacillemia 
prone  to  develop  at  this  time,  but  a  great  quantity  of  blood  is  passed 
through  the  placenta.  The  larger  amount  of  blood  present  in  the  pla- 
cental sinuses  and  the  relatively  slow  blood  current  at  this  period  predis- 
pose to  the  enmeshing  of  tubercle  bacilli  circulating  in  the  maternal  blood 
stream.  The  placenta  itself  is  probably  more  receptive  to  tuberculosis 
than  during  its  earlier  development.  Langhans'  layer  of  cells  is  absent. 
As  the  end  of  pregnancy  approaches,  the  placenta  assumes  characteristics 
that  have  caused  it  to  be  termed  a  senile  organ  (Williams,5  Eden,152 
Warthin,  Cowie,12  and  others).  Very  early  hematogenous  infection  is 
also  unlikely  to  take  place ;  indeed,  during  the  first  few  weeks  the  chorionic 
villi  are  devoid  of  blood  vessels  and  are  nourished  entirely  by  osmosis. 


62    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

As  has  previously  been  stated,  some  authorities  regard  the  placenta 
as  a  secure  filter  that  prevents  the  organisms  of  a  maternal  bacteriemia 
from  graining  access  to  the  fetus.  This  view  is  correct  to  a  certain 
extent.  This  theory  is  based  upon  the  assumption  that  the  syncytium 
of  the  placenta  is  everywhere  intact.  In  the  latter  months  of  pregnancy 
the  chorion  undergoes  progressive  atrophy.  Anemic  infarcts  are  con- 
stantly present  in  the  placenta,  and  at  these  points  egress  is  offered  for 
the  maternal  microorganisms.  It  is  probable  that  the  fibrinous  exudate 
which  forms  in  these  areas  is  an  important  factor  in  safeguarding  the 
fetus.  The  bactericidal  properties  of  the  blood  are  perhaps  also  sufficient 
to  destroy  or  inhibit  the  growth  of  a  certain  proportion  of  the  tubercle 
bacilli.  Indeed,  Warthin  and  Cowie  believe  that  it  is  only  under  excep- 
tional circumstances,  or  when  the  organisms  are  present  in  large  numbers, 
that  transmission  is  likely  to  occur. 

When  tubercle  bacilli  are  present  in  the  intervillous  spaces,  labor 
itself,  with  its  incident  strong  and  frequent  uterine  contractions,  is  espe- 
cially prone  to  force  the  microorganisms  into  the  fetal  blood  stream. 
That  labor  is  a  powerful  agent  in  the  production  of  congenital  tubercu- 
losis has  been  recognized  by  practically  all  observers ;  in  fact,  Bardeleben 
goes  so  far  as  to  perform  a  cesarean  section  as  a  prophylactic  operation 
before  the  onset  of  labor  in  certain  cases. 


PREDISPOSING    FACTORS    TO    PLACENTAL    OR    CON- 
GENITAL TUBERCULOSIS 

As  most  of  these  factors  have  been  mentioned  in  the  preceding  pages, 
only  a  summary  will  here  be  given.  Excluding  the  germinative  type, 
the  existence  of  which  rests  merely  upon  a  theoretic  basis,  the  require- 
ments for  a  placental  infection  to  take  place  are  a  tuberculous  bacillemia 
or  a  tuberculous  focus  in  the  immediate  neighborhood  of  the  placental 
site.  Under  predisposing  factors,  therefore,  must  be  placed  all  conditions 
that  favor  the  presence  of  tubercle  bacilli  in  the  maternal  blood  stream, 
such  as  acute  miliary  tuberculosis,  phthisis  florida,  ulcerative  lesions 
that  tend  to  rupture  into  blood  vessels,  acute  exacerbations  of  the  disease, 
and  a  high  temperature,  which  in  itself  tends  to  destroy  the  continuity 
of  the  blood  vessels.  In  this  connection,  however,  it  must  be  remarked 
that  Warthin  has  recently  described  a  case  of  placental  tuberculosis  in 
which  the  lung  lesion  was  quiescent,  and  the  attention  of  the  attending 
physician  was  called  to  the  tuberculosis  only  by  the  finding  of  miliary 
tubercles  in  the  placenta. 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  63 

Syphilis  and  other  disease  of  the  placenta,  as  well  as  trauma,  prob- 
ably not  only  predispose  to  the  development  of  placental  tuberculosis, 
but  undoubtedly  serve  as  predisposing  factors  in  the  production  of 
congenital  tuberculosis  by  forming  avenues  of  egress  for  the  circulating 
or  enmeshed  tubercle  bacilli. 

Tuberculosis  of  the  peritoneum  or  of  the  female  genital  tract  is  also 
a  predisposing  factor  to  infection.  The  author  has,  however,  seen  two 
cases  of  advanced  tuberculous  peritonitis  in  pregnant  women,  and  in 
neither  was  there  gross  evidence  of  infection  in  any  of  the  products  of 
conception.  Unfortunately  a  thorough  examination  could  not  be  made 
in  either  case.    Williams  has  observed  a  somewhat  similar  case. 

The  Fate  of  the  Congenitally  Tuberculous. — Under  this  heading 
Cornet  formulates  an  extremely  unfavorable  prognosis  for  children  who 
are  the  victims  of  this  variety  of  infection.  Embryonic  and  fetal  tissues 
possess  no  immunity  to  tuberculosis.  It  is  probable  that,  if  the  fetus 
were  infected  during  the  early  months  of  pregnancy,  intra-uterine  death 
or  abortion  would  be  likely  to  follow,  whereas  if  the  infection  occurred 
late,  it  is  probable  that  tuberculosis  would  manifest  itself  in  the  liver  or 
adjacent  lymphatic  glands.  It  would  appear,  therefore,  that  the  prognosis 
would  be  decidedly  less  favorable  in  the  case  of  a  congenitally  infected 
child  than  in  one  who  acquired  the  disease  postnatally.  Furthermore, 
the  virulence  of  the  strain  of  an  infecting  organism  is  of  importance  in 
this  connection.  The  mothers  of  congenitally  infected  children  are  often 
the  incumbents  of  an  acute  miliary  tuberculosis,  a  form  of  disease  in 
which  the  organisms  are  usually  extremely  virulent. 

A  few  years  ago  the  author  reported  the  results  obtained  in  the 
examinations  of  fourteen  placentas  from  tuberculous  women.  Since 
these  107  additional  specimens  have  been  examined,  making  a  series  of 
121  placentas.  The  subjects  from  which  these  placentas  were  obtained 
were  all  suffering  from  pulmonary  tuberculosis.  They  consisted  for 
the  most  part  of  ambulatory  cases,  which  were  coming  to  the  Henry 
Phipps  Institute  for  treatment.  Almost  15  per  cent  were  in  a  mod- 
erately acute  stage  of  the  disease  at  the  time  of  delivery,  and  two  were 
nearly,  moribund.  The  remainder  were  mild  or  quiescent.  One  hundred 
and  one  were  at  or  nearly  at  term ;  the  remainder  were  premature,  some 
as  early  as  the  second  month.  In  brief,  the  following  technic  was  em- 
ployed: five  to  ten  small  pieces  were  cut  from  various  parts  of  the 
placenta  and  were  finely  ground  up  with  sand  in  a  mortar,  to  which 
was  added  a  little  salt  solution.  This  was  allowed  to  stand  for  a  short 
time,  and  about  a  dram  of  the  solution  was  injected  into  the  peritoneal 
cavity  of  a  guinea  pig,  five  pigs  being  used  for  each  placenta.    All  pigs 


64         GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

dying  after  the  fifth  day  were  autopsied,  and  at  the  end  of  six  weeks  all 
the  remaining  animals  were  killed  and  examined.  A  case  was  considered 
positive  for  tubercle  bacilli  where  three  of  the  five  inoculated  pigs 
showed  tuberculosis.  There  were  fourteen  such  cases.  Inoculations 
from  three  additional  placentas  showed  tuberculosis  in  one  or  two  of 
the  five  pigs  injected.  Specimens  in  which  all  the  inoculated  animals 
died  during  the  week  subsequent  to  inoculation  are  not  included  in  this 
series.  Thus  virulent  tubercle  bacilli  were  demonstrated  with  moderate 
certainty  in  n  per  cent  of  the  specimens,  and  may  have  been  present 
in  an  additional  2  per  cent  of  the  placentas. 

CONGENITAL  TUBERCULOSIS 

(Case  Histories) 

Undoubted  Cases. — In  the  following  cases  the  diagnoses  were  based 
upon  anatomical  changes  and  the  presence  of  tubercle  bacilli. 

Sabouraud.123  Child  aged  eleven  days,  born  of  mother  in  advanced 
stage  of  pulmonary  tuberculosis,  who  died  shortly  after  delivery. 
Autopsy  of  infant  showed  the  presence  of  countless  miliary  tubercles  in 
the  liver  and  spleen,  in  part  showing  caseation,  and  containing  tubercle 
bacilli. 

Lehmann.153  Woman  forty  years  of  age,  suffering  from  advanced 
pulmonary  tuberculosis,  gave  birth  to  a  premature,  male  child  in  the 
ninth  month.  The  mother  died  two  days  after  delivery.  Autopsy 
showed  acute  miliary  tuberculosis  of  lungs  and  tuberculous  meningitis. 
The  placenta  was  not  examined.  The  child  died  twenty-four  hours  after 
birth.  Autopsy  showed  miliary  tuberculosis  of  the  lungs,  liver,  spleen, 
and  kidneys.  Tubercles  were  also  present  in  the  portal,  mediastinal, 
bronchial,  mesenteric,  and  retroperitoneal  glands.  The  microscopic 
appearance  was  that  of  typical  tubercles.  Large  numbers  of  tubercle 
bacilli  were  found.  No  giant  cells  were  present  in  the  tubercles. 
Advanced  stage  of  the  process  makes  the  case  undoubtedly  congenital. 

Honl.154  Child,  fifteen  days  old.  Autopsy  revealed  typical  caseous 
miliary  nodules  in  the  spleen,  liver,  lungs,  containing  numerous  tubercle 
bacilli.  These  were  also  found  free  in  the  blood  vessels.  Chronic 
tuberculous  lesions  were  found  in  the  liver.  Mother  was  brought  to 
the  hospital  with  pulmonary  tuberculosis  after  birth  of  child.  The  case 
is  regarded  as  undoubtedly  congenital,  as  such  advanced  lesions  could 
not  have  formed  during  the  short  period  of  extra-uterine  life. 

Ustinow.155     New  born  female  child  weighing  3,060  gms.     Died  of 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  65 

inanition  after  a  few  days.  Nothing  known  of  the  mother.  Autopsy 
of  infant  showed  general  tuberculosis,  most  marked  in  the  liver.  The 
spleen  was  somewhat  enlarged,  and  contained  so*  many  tubercles  that 
the  surface  presented  a  marbled  appearance.  Lungs  contained  a  smaller 
number  of  tubercles.  The  brain  and  retina  of  both  eyes  were  free  from 
tubercles.  Large  numbers  of  tubercle  bacilli  were  found  in  the  tubercles 
and  also  free  in  the  capillaries.  In  some  sections  the  bacilli  were  so 
numerous  that  when  stained  for  tubercle  bacilli  the  red  areas  were  visible 
to  the  naked  eye. 

Auche  and  Chambrelente.156  Mother,  in  advanced  stage  of  tubercu- 
losis, died  three  days  after  a  premature  delivery  in  the  seventh  month. 
Autopsy  showed  advanced  tuberculosis  of  the  lungs,  liver,  spleen,  intes- 
tines, mesenteric  glands,  and  kidneys.  The  uterus  and  adnexa  were 
normal.  Peritonitis  was  not  present.  The  placenta  showed  numerous 
caseous  tubercles  with  tubercle  bacilli.  Inoculation  of  guinea  pigs  with 
portions  of  placenta  gave  positive  results.  Child  died  on  the  twenty-sixth 
day.  Autopsy  showed  miliary  tubercles  in  the  lungs,  liver,  spleen,  and 
endocardium  of  the  right  heart.  Typical  tubercle  bacilli  were  present. 
Inoculation  of  rabbit  with  portions  of  fetal  organs  gave  positive  results. 
The  tuberculous  endocarditis  is  of  especial  interest,  as  the  first  case  noted 
in  infants.    The  woman  had  three  other  healthy  children. 

Veszpremi 157  reports  a  case  of  congenital  tuberculosis.  Tubercle 
bacilli  were  demonstrated  from  the  fetal  blood  by  means  of  inoculation. 
The  mother  was  the  victim  of  advanced  miliary  tuberculosis.  Owing 
to  unfortunate  circumstances,  it  was  not  possible  to  examine  the  placenta. 

Dufour  and  Thiers 158  report  a  case  of  tuberculosis  of  a  fetus. 
Mother,  aged  nineteen  years,  having  symptoms  of  advanced  pulmonary 
and  meningeal  tuberculosis.  The  latter  was  proved  by  puncture  and 
demonstration  of  the  microorganism.  She  died  twelve  days  after  admis- 
sion to  the  hospital.  Autopsy  showed  extensive  tuberculosis.  The  fetus 
was  partially  expelled  into  the  vagina.  The  abdomen  was  enlarged  and 
ascitic.  The  placenta  was  macerated  and  suggestive  of  tuberculosis  in 
its  appearance.  Acitic  fluid  from  the  chest  of  the  fetus,  by  inoculation, 
was  found  to  contain  tubercle  bacilli.  The  placenta  showed  histologic 
evidence  of  tuberculosis,  but  tubercle  bacilli  were  not  demonstrated  in  it. 

Brindeau.159  The  child  of  a  tuberculous  mother,  died  on  the  twelfth 
day.  Autopsy  showed  very  advanced  pulmonary  lesions,  and  from  these 
tubercle  bacilli  were  demonstrated.  The  advanced  character  of  the 
lesion  present  makes  it  extremely  probable  that  this  case  was  one  of  true 
congenital  infection. 

Stockel.160    The  mother  had  advanced  tuberculosis.    No  tuberculosis 


66  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

was  found  in  the  placenta.  The  child  lived  fourteen  days.  At  autopsy 
the  cadaver  showed  extensive  miliary  tuberculosis,  especially  of  the  lungs, 
liver,  and  intestines,  and  marked  caseations,  especially  of  the  periportal 
glands. 

Zarfl.161  The  infant  was  born  of  a  tuberculous  mother.  On  the 
seventeenth  day  the  von  Pirquet  reaction  was  markedly  positive.  The 
author  believes  such  sensitiveness  to  tuberculosis  could  not  have  developed 
in  seventeen  days.  On  the  eighteenth  day  there  was  enlargement  of  the 
liver  and  spleen.  The  swelling  of  the  spleen  increased  and  was  the 
most  prominent  symptom.  Until  the  last  week  there  was  no  clinical 
or  Rontgen  ray  evidence  of  tuberculosis.  This  child  died  on  the  fifty- 
second  day.  Autopsy  showed  involvement  of  lymph  nodes  of  the  liver 
region,  the  most  seriously  involved.  Slight  involvement  of  bronchial 
lymph  nodes  and  no  focus  in  the  lungs.  The  mother  lived  for  three 
months  after  the  birth  of  the  child. 

Jens  Bugge.162  The  patient,  aged  thirty-nine  years,  died  of  tubercu- 
losis four  days  after  delivery.  Autopsy  showed  tuberculosis  of  the  lungs, 
bronchial  glands,  kidneys,  and  intestinal  tract.  The  placenta  was  not 
examined.  The  infant  was  eight  months  advanced  and  died  thirty  hours 
after  delivery.  No  tuberculosis  was  found  macroscopically,  but  tubercle 
bacilli  in  the  umbilical  vein  were  demonstrated  by  staining  and 
inoculation. 

Moller  163  reports  a  case  of  tuberculosis  in  a  child  which  died  on  the 
third  day.  The  mother  left  the  hospital  well,  but  returned  five  months 
afterward  with  tuberculosis  of  the  uterus,  and  died  of  miliary  tubercu- 
losis in  two  months.  Autopsy  of  the  child  showed  miliary  tuberculosis 
of  the  liver  and  spleen,  a  tubercle  in  the  pancreas,  two  typical  ulcers  in 
the  ileum,  miliary  tuberculosis  of  the  lungs,  massive  tuberculosis  of  the 
retroperitoneal  lymph  glands,  and  a  caseous  mass  in  the  thymus. 
Tubercle  bacilli  were  found  in  the  lesions.  Recent  tuberculosis  lesions 
were  found  in  the  decidual  membrane  and  panhysterectomy  was  per- 
formed. Old  tuberculosis  processes  were  evident  in  both  fallopian 
tubes,  and  to  these  Moller  attributes  the  infection  of  the  uterus  and 
the  fetus.  When  the  woman  was  delivered  there  was  no  suspicion  of 
tuberculosis  and  the  placenta  was  not  examined. 

Grulee  and  Harms  164  reported  a  case  of  miliary  tuberculosis  in  a 
child  which  died  on  the  eleventh  day.  This  child  showed  throughout  an 
irregular  temperature.  On  the  fifth  day  it  had  a  convulsion  which  con- 
tinued until  death.  The  liver  and  spleen  were  found  to  be  enlarged.  At 
autopsy  there  were  found  caseous  tubercles  of  the  periportal  and  mesen- 
teric  lymph   glands,    miliary   tuberculosis   of   the   spleen   with   caseous 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  67 

nodules,  and  a  few  scattered  nodules  in  the  liver,  lungs,  and  kidneys. 
The  mother  of  this  child  had  what  was  apparently  only  a  healed  tuber- 
culosis of  the  hip.  She  had,  however,  a  vaginal  discharge  of  unknown 
etiology.  The  mother  was  alive  several  months  after  the  infant  was 
born. 

Probable  and  Doubtful  Cases. — In  these  cases  the  diagnoses  were 
based  upon  anatomical  appearance  only,  gross  or  microscopic,  without 
demonstration  of  the  presence  of  tubercle  bacilli ;  or  doubtful  because 
of  age  of  child,  non-elimination  of  possible  syphilis,  extra-uterine  in- 
fection, etc. 

Delmas.165  The  mother  was  moribund  from  advanced  phthisis  at 
the  time  of  her  confinement.  The  child  was  delivered  by  forceps  and 
immediately  placed  in  a  sterilized  incubator.  No  further  communication 
between  the  mother  and  child  occurred.  The  child  died  when  four 
months  old,  the  lungs  being  chiefly  affected.  Delmas  believes  the 
infection  to  have  been  a  hematogenous  one.  There  were  no  intestinal 
lesions. 

Bourges.160  The  mother  died  of  tuberculosis  shortly  after  having 
been  delivered  of  a  viable  child.  At  autopsy  she  showed  advanced 
lesions.  The  child  survived  but  a  short  time.  An  autopsy  on  it  showed 
no  macroscopic  evidence  of  tuberculosis,  but  inoculations  from  the  liver 
and  other  areas  into  guinea  pigs  gave  a  positive  result.  In  another  case, 
negative  results  were  obtained. 

Jacobi.122  Seven  months'  fetus  of  a  mother  suffering  from  chronic 
pulmonary  tuberculosis  had  numerous  caseating  tubercles  in  liver,  spleen, 
pleura,  and  peritoneum.     Anatomical  evidence  only. 

Demme.167  Two  cases  :  1.  Boy  of  five  weeks.  Sick  from  birth  with 
fever  and  cough ;  showed  on  autopsy  caseous  nodules  in  both  lungs  and 
infiltration  of  bronchial  and  tracheal  glands.  Mother  died  of  chronic 
pulmonary  tuberculosis  soon  after  delivery.  2.  Child  died  on  sev- 
enteenth day  after  delivery.  Similar  to  the  first  case.  Tuberculosis  in 
mother  shown  by  physical  signs.    Both  cases  are  doubtful. 

Charrin.121  Seven  and  a  half  months  child  of  a  tuberculous  mother ; 
died  three  days  after  birth.  Autopsy  showed  widespread  tuberculosis 
of  the  peritoneum  and  abdominal  organs.  Scattered  tubercles  were 
found  in  the  lungs.    Anatomical  evidence  only. 

Demme.167  Female  child,  twelve  days  old,  of  tuberculous  mother. 
Autopsy  showed  caseous  bronchial  glands  and  numerous  caseating 
nodules  in  both  lungs.  In  the  right  apex  and  right  lower  lobe  many 
cavities,  the  size  of  a  pea  to  a  cherry,  are  found.  Mesenteric  glands  are 
unchanged.     Doubtful  case.     Anatomical  evidence  only. 


68  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Merkel.168  (Not  reported  until  1884  by  Ohlendorff).  In  January, 
1875,  patient  developed  pleuritis,  followed  by  bronchial  catarrh  and 
infiltration  of  apices.  In  February  she  conceived;  in  June  showed  tuber- 
culous laryngitis;  by  October  the  patient  had  to  be  fed  with  tube;  and 
the  child  was  born  on  November  4.  On  the  6th  the  mother  died. 
Autopsy  showed  tuberculous  cavities  in  the  lungs  and  miliary  tubercu- 
losis. The  child  was  small  and  was  born  with  a  small  yellow  tumor  on 
hard  palate.  On  the  second  day  this  discharged  cheesy  material ;  abscess 
then  developed  in  left  greater  trochanter.  Child  died  of  inanition. 
Autopsy  showed  caseous  nodule  in  hard  palate  infiltrating  the  bone, 
caseation  of  cervical  glands,  caseous  nodule  behind  the  left  hip  joint. 
Probable  case.    Anatomical  evidence  only. 

Demme.167  Female  child,  aged  twenty-five  days.  Mother  died  of 
catarrhal  pneumonia.  Autopsy  of  child  showed  in  the  middle  of  the 
right  cerebellar  hemisphere  a  caseating  tubercle  the  size  of  a  hazel  nut. 
The  microscopic  examination  showed  the  appearance  of  caseating 
tubercles.    No  tuberculosis  elsewhere.    Doubtful  case. 

Baumgarten.169  States  that  in  autopsies  on  infants  dying  during  the 
first  months  of  life  he  had  often  found  tuberculosis  of  such  advanced 
stage  as  to  make  a  congenital  origin  very  probable. 

Berti  (cited  by  Gartner).170  Tuberculous  mother,  aged  seventeen 
years.  Child  died  on  the  ninth  day  after  birth.  Autopsy  showed  two 
small  cavities,  filled  with  caseous  material,  in  the  posterior  margin  of 
lower  right  lobe  of  the  lung.  Microscopic  examination  confirmed  the 
gross  diagnosis  of  tuberculosis.  Very  probable  case.  Anatomical 
evidence.  (Berti  reports  a  second  very  doubtful  case,  which  may  be 
entirely  ruled  out.) 

Demme.171  Two  cases:  1.  Child  dying  on  twenty-first  day. 
Autopsy  showed  advanced  tuberculous  ulceration  of  intestines.  2.  Child 
dying  on  twenty-ninth  day  of  pulmonary  tuberculosis.  Both  cases  very 
doubtful.  History  meager.  Evidence,  anatomical  only.  Extra-uterine 
infection  not  excluded. 

Money.172  Female  child  of  tuberculous  mother,  dying  five  weeks 
after  delivery.  Child  ill  for  three  weeks  with  cough  and  attacks  of 
vomiting.  No  evidence  of  syphilis.  Died  in  eighth  week.  Autopsy 
showed  caseous  tubercles  of  lung,  liver,  spleen,  and  kidneys.  Bronchial 
and  mesenteric  glands  enlarged,  but  no  caseation.  Intestines  not 
ulcerated.    One  tracheal  gland  caseated.    A  probable  case. 

Demme.167  Female  child,  aged  eleven  weeks,  of  tuberculous  mother. 
Autopsy  showed  extensive  cavity  formation  in  the  right  lobe  of  the 
child's  lung.    A  doubtful  case.     Extra-uterine  infection  not  excluded. 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  69 

Queyrat.173  Three  months  old  child;  died  and  autopsy  revealed 
extensive  caseation  and  cavity  formation  in  both  lungs.  Mother  healthy; 
father  tuberculous.  Very  doubtful.  Extra-uterine  infection  not 
excluded. 

Flesch.174  Advanced  ulcerative  lesions  were  found  in  the  lungs  of 
eight  out  of  five  hundred  infants  upon  whom  autopsies  were  performed. 
All  the  subjects  had  died  in  the  early  months  of  life.  Extra-uterine 
infection  not  excluded.  Statement  too  inexact.  Evidence,  anatomical 
only. 

Frobelius.175  Found  in  16,581  autopsies  of  children  under  two  years 
of  age,  616  cases  of  tuberculosis.  One  died  on  the  third  day,  one  in 
the  second  week,  one  in  the  third  week,  three  at  about  three  and  one-half 
weeks,  fourteen  in  the  second  month,  and  one  hundred  and  nineteen  in 
the  third  month.     No  detailed  account  of  these  cases  is  given. 

Houtinel.176  In  996  autopsies  upon  infants  under  one  year  of  age, 
eighteen  cases  of  tuberculosis  were  observed,  two  dying  in  the  first 
fourteen  days  after  birth.     No  detailed  account  is  given. 

Lannelongue.177  Out  of  1,005  cases  of  surgical  tuberculosis  in  chil- 
dren under  fifteen  years  of  age,  four  were  observed  which  he  regards 
as  of  undoubted  congenital  origin ;  one  child,  six  weeks  old,  with  classi- 
cal signs  of  tuberculosis  of  knee  existing  from  birth;  one,  one  month 
old,  tuberculous  osteoarthritis  fourteen  days  after  birth ;  one,  three  weeks 
old,  tuberculous  abscesses  in  the  left  tarsus  and  right  maleolar  regions; 
one,  sixteen  days  old,  tuberculous  ostitis.  In  these  cases,  Lannelongue 
believes  it  possible  to  exclude  extra-uterine  infection.  In  another  child 
of  two  months,  right  sided  tuberculous  epididymitis  with  fistula  was 
present.  A  scrotal  engorgement  some  days  after  birth  was  noticed.  Few 
details  are  given  concerning  the  parents.    All  these  cases  are  doubtful. 

Huguenin.178  Two  cases,  one  dying  at  the  age  of  seven  weeks  of 
general  tuberculosis ;  the  second  at  the  age  of  seven  months  of  a  general 
tuberculosis.  Very  doubtful  cases.  Evidence,  anatomical  only.  No 
details  are  given. 

Bosselut.179  In  a  large  number  of  autopsies  on  children  dying  of 
tuberculosis,  meningitis  was  found  in  one  subject  who  had  died  on  the 
fourteenth  day ;  in  two,  aged  three  weeks ;  in  one,  aged  six  weeks ;  and 
in  four,  aged  eight  weeks.  Evidence  not  conclusive.  No  details. 
Doubtful  cases. 

Rindfleisch.180  Mother  in  advanced  phthisis  florida,  developing 
during  pregnancy,  and  died  of  phthisis  shortly  after  birth  of  child.  The 
child  died  on  the  eighth  day  of  general  tuberculosis.  Large  caseous 
nodules  in  the  liver.    Probable  case.    Anatomical  evidence  only. 


70         GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Sarwey.181  Monster  (cranioschisis)  ;  prolonged  pregnancy.  Born 
in  eleventh  month.  The  mother  was  apparently  healthy.  Father  had 
cough  and  tubercle  bacilli  in  the  sputum.  Child  showed  caseous  and 
partly  calcified  nodules  in  the  upper  cervical  vertebrae.  Guinea  pigs  were 
inoculated.  Three  out  of  six  developed  tuberculosis  after  three  months. 
A  probable  case. 

Baumgarten.169  Still  born  monster  (encephalocele).  Caseating 
abscesses  in  three  uppermost  cervical  vertebrae.  No  bacilli  found. 
Evidence  only  anatomical.     Details  not  given.     A  doubtful  case. 

Leroux.116  The  infant  died  when  eighteen  days  old.  Deep  tuber- 
culosis ulcers  were  found  in  the  intestine.  Caseation  of  tracheal  and 
bronchial  glands  was  present.  Probably  a  case  of  congenital  infection, 
as  the  extensive  changes  could  hardly  have  occurred  from  extra-uterine 
infection. 

Leroux  also  gives  notes  of  twenty-two  other  cases  of  tuberculosis 
in  children  under  three  months ;  one,  four  weeks  old ;  one,  five  weeks 
(premature  birth)  ;  two,  six  months;  five,  two  months;  eight,  two  and 
one  half  months;  five,  two  and  three  quarter  months.  No  details  given. 
All  these  cases  are  doubtful  and  based  upon  clinical  observations 
only. 

Wassermann.182  Child  when  first  taken  ill  was  six  weeks  old,  and  at 
that  time  had  bronchial  catarrh  and  osteitis  (tuberculous?).  Died  four 
and  one  half  weeks  later.  Autopsy  showed  extensive  tuberculosis  of 
both  lungs,  diaphragm,  liver,  and  kidneys.  Wassermann  believed  the  case 
to  be  acquired  from  a  relative  of  the  mother,  with  whom  the  latter  and 
child  had  resided  for  a  short  time  when  the  child  was  ten  days  old. 
Correctness  of  this  opinion  questioned  by  Baumgarten  and  Lebkuchner. 
Very  doubtful  case. 

Hochsinger  104  reports  three  cases,  aged  thirty-one  days,  thirty-eight 
days,  and  sixteen  weeks,  respectively,  of  combined  tuberculosis  and 
syphilis.  The  mother  in  the  first  and  third  cases  was  tuberculous. 
Autopsies  of  children  showed  advanced  tuberculosis  in  all  three  cases. 
Tubercle  bacilli  present  in  all.  Age  of  children  and  the  fact  that  con- 
genital syphilis  predisposes  to  rapid  development  of  tuberculosis  make 
these  cases  doubtful. 

Straus.183  Child  died  when  three  weeks  old.  Autopsy  showed 
caseous  tubercles  in  lung,  spleen,  bronchial,  and  mesenteric  glands. 
Doubtful  case.     Full  details  not  given. 

Kissel.184  In  one  thousand  autopsies  upon  children,  Kissel  observed 
three  cases  of  tuberculosis  which  he  believed  to  be  of  congenital  origin. 
These  children  were  aged  four,  five,  and  six  weeks,  respectively.     Small 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  71 

advanced  lesions  of  the  bronchial  glands  were  present.     The  cases  are 
not  reported  in  detail  and  must  be  considered  as  doubtful. 

Holt 185  mentions  one  case,  of  a  child  dying  on  the  twentieth  day 
after  a  premature  birth.  The  mother,  suffering  from  advanced  tuber- 
culosis, died  shortly  after  the  child.  On  autopsy,  the  child  was  found 
to  have  caseous  bronchial  glands,  and  miliary  tuberculosis  of  the  lungs, 
none  in  liver,  alimentary  tract,  or  spleen.  Regarded  as  probably 
congenital  from  advanced  nature  of  lesions. 

Henoch.186  Father  died  of  tuberculosis.  The  child  had  been  ill 
since  the  sixth  week  from  multiple  tuberculous  abscesses  in  various  parts 
of  the  body.  It  died  in  the  fourth  month,  of  inanition.  Autopsy  showed 
advanced  pulmonary  tuberculosis,  intestinal  tuberculosis,  and  caseation 
of  lymph  glands.  A  very  doubtful  case.  Extra-uterine  infection 
probable. 

Bonnet.187  Mother  died  of  pulmonary  tuberculosis  two  months  after 
delivery.  Male  child,  ill  from  birth,  died  at  three  months.  Autopsy 
showed  both  lungs  studded  with  caseous  tubercles,  tuberculous  ulcers 
in  ileum,  caseous  tuberculosis  'in  mesenteric  glands,  kidneys,  spleen  and 
liver.  Fatty  liver.  The  stage  of  lesions  and  the  fact  of  illness  from 
birth,  the  child  having  been  kept  from  danger  of  infection,  given  as 
reasons  for  regarding  the  case  as  of  congenital  origin. 

Johnson.188  White  female  child  born  of  mother  suffering  from 
tuberculosis  of  urinary  tract.  At  birth  the  infant  was  very  weak,  small, 
and  could  not  nurse.  The  emaciation  increased.  The  child  made  efforts 
at  coughing  and  died  during  a  profuse  pulmonary  hemorrhage  at  the 
age  of  three  months  and  two  days.  The  father  was  healthy.  Urine  of 
mother  contained  blood,  pus,  and  tubercle  bacilli.  Placental  tuberculosis 
was  probably  present,  the  organ  showing  the  usual  histologic  evidence 
of  this  infection.  Autopsy  of  child  showed  extensive  tuberculosis  of 
the  right  lung  pleura,  and  pericardium;  miliary  tuberculosis  of  the  left 
lung.  Tubercle  bacilli  could  not  be  found  in  fetal  organs.  Evidence 
not  complete,  but  most  probably  a  case  of  congenital  tuberculosis. 

Lebktichner.189  Two  cases:  1.  The  mother  was  of  a  tuberculous 
family ;  suspicious  symptoms,  but  case  not  certain.  The  child  was  short 
of  breath  and  coughed  from  birth.  It  eventually  died,  and  a  postmortem 
showed  advanced  tuberculosis  in  lungs  and  other  organs.  2.  Case  simi- 
lar, but  child  older.  The  first  case  may  be  regarded  as  probable,  though 
the  evidence  is  incomplete. 

Friedmann.190  The  mother  had  advanced  tuberculosis.  The  child 
died  when  twenty-six  days  old ;  a  postmortem  showed  a  small  tuberculous 
lesion  in  the  apex  of  the  right  lung.    Evidence  not  conclusive. 


72         GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Lyle.191  Negress,  twenty-two  years  of  age,  in  seventh  month  of 
pregnancy,  suffering  from  chronic  pulmonary  tuberculosis.  The  mother 
died  two  days  after  premature  delivery.  Autopsy  showed  chronic  tuber- 
culosis of  both  lungs  and  intestinal  ulceration.  The  placenta  appeared 
normal.  The  child  weighed  about  three  pounds.  It  was  ill  from  birth ; 
subnormal  temperature  for  four  weeks,  followed  by  fever;  died  in 
eighteenth  week.  Autopsy  revealed  extensive  tuberculosis  of  lungs,  liver, 
spleen,  and  kidneys ;  tubercle  bacilli  were  present  in  the  caseous  areas.  The 
great  number  of  tubercles  of  same  advanced  stage,  the  fact  that  the  child 
was  ill  from  birth  and  had  been  kept  under  such  conditions  as  to  exclude 
likelihood  of  extra-uterine  infection,  are  the  reasons  advanced  by  Lyle 
for  considering  this  case  as  congenital.  It  is  doubtful,  however,  because 
of  the  age  of  the  child. 

Sitzenfrey.11  i.  Patient  aged  thirty-eight  years  and  octipara.  Three 
children  are  living.  She  was  delivered,  by  forceps,  of  a  female  infant, 
which  weighed  2,620  grams.  The  patient  died  five  days  post  partum. 
Autopsy  showed  pulmonary  tuberculosis,  tuberculous  ulcers  of  the  intes- 
tines, chronic  tuberculosis  of  the  peribronchial,  mesenteric,  and  retro- 
peritoneal lymph  glands,  subacute  miliary  tuberculosis  of  the  liver,  spleen, 
and  kidneys,  also  meningitis  basilaris  tuberculosa.  Tuberculous  caries  in 
the  tenth  and  eleventh  ribs  (left)  with  fistula;  also  caries  in  the  second 
to  sixth  dorsal  vertebrae  with  prevertebral  abscess.  The  infant  was 
transferred  at  once  to  an  institution  and  died  six  weeks  after  birth. 
Autopsy  showed  chronic  pulmonary  tuberculosis,  chronic  tuberculosis 
of  the  liver,  spleen,  thyroid,  intestines,  peribronchial,  mesenteric,  retro- 
peritoneal and  portal  lymph  glands.  Case  2.  Patient  aged  twenty-four 
years  and  quadripara.  Two  children  died  of  gastro-intestinal  trouble; 
one  child  is  living  and  well.  She  had  a  spontaneous  delivery  of  an  eight 
months  male  infant,  which  weighed  1,800  grams,  and  which  died  two 
days  after  birth.  The  mother  died  the  following  day.  Autopsy  showed 
chronic  pulmonary  tuberculosis,  chronic  tuberculosis  of  the  peribronchial, 
cervical,  and  axillary  lymph  glands,  tuberculous  ulcer  of  the  larynx, 
tuberculous  nodules  in  the  skin  of  various  portions  of  the  body,  chronic 
tuberculosis  of  the  intestines,  liver,  peritoneum,  and  kidneys,  and  tuber- 
culous meningitis.  The  inner  surface  of  the  lower  uterine  segment  was 
yellow  and  caseous,  but  showed  microscopically  merely  necrosis — no 
tuberculosis.  The  child  died  on  the  second  day.  Autopsy  showed  partial 
atelectasis  of  lungs,  icterus  neonatorum  and  debilitas  vitae  congenita. 
The  placenta  measured  eleven  by  twelve  centimeters.  It  was  macro- 
scopically  normal,  but  the  membranes  show  at  two  places,  corresponding 
to  the  decidua  vera,  a  certain  amount  of  thickening  three  to  four  milli- 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  73 

meters.  The  maternal  surface  of  these  is  uneven,  ragged,  and  grayish 
yellow.  On  section  through  these  areas,  the  tissue  shows  a  caseous 
condition.  On  the  fetal  side,  these  areas  are  covered  by  smooth  amnion. 
Microscopic  examination  of  the  placenta  and  umbilical  cord  is  negative 
for  tuberculosis.  Microscopic  examination  of  the  thickened  portion  of 
the  membranes,  however,  shows  extensive  caseous  foci,  often  associated 
with  thrombosis  in  the  decidua  vera.  In  these  areas  giant  cells  are  not 
found,  but  enormous  quantities  of  tubercle  bacilli  are  seen. 

Sitzenfrey  believes  the  entrance  of  tubercle  bacilli  into  the  fetal 
circulation  in  these  cases  may  be  explained  perhaps  by  the  aberrant 
nutrient  vessels  of  the  chorion,  which  arise  from  the  umbilical  cord  and 
which  might  be  invaded  by  tuberculous  foci  in  the  decidua  vera. 

Two  cases  have  been  reported  by  Schrumpf.  Case  1.  Patient, 
aged  thirty  years,  died  in  seventh  month  of  pregnancy,  from  chronic 
pulmonary  tuberculosis.  The  decidua  vera  in  the  right  and  posterior 
uterine  walls  was  found  transformed  into  a  caseous  sheet,  three  and  a 
half  by  five  centimeters  and  four  millimeters  thick.  Microscopically  this 
tissue  is  full  of  round  cell  infiltration  with  tubercle  bacilli  and  necrosis. 
There  was  no  extension  to  the  placenta  or  decidua  basalis.  Examination 
of  the  fetal  organs  showed  these  to  be  histologically  normal,  but  a  few 
tubercle  bacilli  were  found  in  smear  preparations  from  the  fetal  heart, 
blood  and  liver.  Case  2.  Patient,  aged  twenty-three  years,  died  in  the 
seventh  month  of  pregnancy  from  chronic  pulmonary,  laryngeal  and 
intestinal  tuberculosis.  The  uterine  mucosa  showed  an  opaque,  bright 
yellow  area,  one  centimeter  in  thickness  on  the  posterior  wall  and  extend- 
ing downwards  from  the  outer  edge  of  the  placenta  for  about  seven  centi- 
meters. Microscopically  this  proved  to  be  an  infiltration  of  the  decidua 
vera  with  necrosis  in  places  and  a  few  tubercle  bacilli.  No  miliary 
tubercles  or  giant  cells.  The  placenta  and  decidua  basilaris  were  normal. 
Examination  of  the  fetus  and  animal  inoculation  were  negative. 

Sitzenfrey  also  reports  two  other  cases  which  he  believes  to  have 
been  congenital  and  which  have  been  excluded  on  account  of  the  age  at 
which  the  children  died,  three  months  and  six  months,  respectively. 

PLACENTAL  TUBERCULOSIS 

(Case  Histories) 

Undoubted  Cases.— Diagnoses  rest  upon  demonstration  of  histo- 
logical changes  and  the  presence  of  tubercle  bacilli  in  the  placenta. 
Runge  81  reports  a  case  of  placental  tuberculosis  occurring  in  a  patient 


74  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

suffering  from  active  pulmonary  lesions.  The  tubercle  bacilli  were  dem- 
onstrated in  the  placenta,  and  the  characteristic  histologic  changes 
produced  by  this  organism  were  present. 

Lehmann.192  Case  I.  Woman,  aged  twenty-six  years,  died  of  miliary 
tuberculosis  in  seventh  or  eighth  month  of  pregnancy.  Male  child  re- 
moved by  cesarean  section  five  minutes  after  death  of  mother,  showed 
no  signs  of  life.  Well  developed.  The  only  abnormal  changes  found 
were  two  grayish  nodules  in  the  right  apex.  Pieces  of  liver  and  spleen 
were  inoculated  into  guinea  pigs.  The  general  appearance  of  the  placenta 
was  normal.  In  several  places  small  miliary  nodules  grayish,  semi- 
translucent,  and  sharply  outlined,  were  found.  The  microscopical  exam- 
ination of  fetal  liver  and  lungs  gave  no  appearance  of  tuberculosis.  No 
tubercle  bacilli  were  found.  The  placental  nodules  presented  the  appear- 
ance of  typical  caseating  tubercles,  containing  a  few  tubercle  bacilli. 
Case  2.  The  woman,  aged  thirty-two  years,  died  in  the  hospital.  No 
history  of  the  case  was  obtainable.  The  autopsy  showed  tuberculosis 
of  the  lungs,  endocardium,  liver,  both  kidneys,  meninges  and  the  pul- 
monary veins.  The  uterus  measured  fourteen  by  nine  by  eight  centi- 
meters. On  its  anterior  and  posterior,  surf  aces  were  small,  grayish  pro- 
tuberances. The  uterine  wall  was  one  and  a  half  to  two  centimeters 
thick  and  very  vascular.  The  cavity  contained  an  ovum  of  about  four 
months'  development.  A  loop  of  the  cord  had  prolapsed  into  the  vagina. 
The  placenta  measured  one  to  one  and  a  half  centimeters  in  thickness 
and  was  anterior  in  attachment.  There  were  small  hemorrhages  in  the 
placenta  and  a  larger  one  between  it  and  the  uterine  wall,  showing  that 
abortion  must  have  begun  before  death.  The  adnexa  were  normal. 
Tuberculous  granulation  tissue  was  found  surrounding  the  chorionic  villi, 
and  in  a  few  tubercle  bacilli  were  demonstrated. 

Harbitz.193  The  mother  was  twenty-six  years  of  age  and  entered 
the  hospital  with  advanced  pulmonary  tuberculosis,  of  which  she  died 
twenty-eight  days  after  confinement.  Autopsy  showed  an  acute  miliary 
tuberculosis,  involving  the  lungs,  kidneys,  peritoneal  cavity,  and  fallopian 
tubes.  The  uterus,  especially  in  the  vicinity  of  the  decidua  basilaris, 
showed  well  marked  tuberculosis.  The  infant  measured  forty-nine  centi- 
meters in  length  and  weighed  1,930  grams.  It  died  on  the  twenty-fifth 
day,  having  been  previously  isolated  from  the  mother.  Autopsy  upon 
it  showed  extensive  involvement  of  the  lungs  and  bronchial  lymph  glands. 

Warthin.194  Patient,  aged  twenty  years,  with  a  previous  history  of 
gonorrhea.  Tuberculosis  was  not  suspected,  but  during  the  routine 
course  of  the  histologic  examination  of  the  placenta,  as  practiced  in  Dr. 
Peterson's  clinic,   numerous  miliary  tubercles,  many  of  them  healing, 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  75 

were  found.  In  some  of  these  areas,  tubercle  bacilli  were  demonstrated 
by  staining.  Examination  of  the  mother  showed  a  positive  tuberculin 
test,  a  suspicious  right  apex,  but  no  evidence  of  active  disease.  The 
child  was  viable,  and  no  tuberculosis  demonstrated  in  it. 

Carl.195  The  mother  showed  advanced  pulmonary  tuberculosis  and 
the  usual  clinical  symptoms.  The  child  was  normal,  but  in  the  placenta 
typical  tubercle  bacilli  were  demonstrated,  together  with  the  histologic 
evidence  of  this  infection. 

Lehmann.153  Mother  died  of  chronic  tuberculosis  of  lungs  and 
larynx.  The  child  died  ten  days  after  birth.  It  presented  no  evidence 
of  tuberculosis  at  autopsy.  Typical  caseating  tubercles  containing 
tubercle  bacilli  found  in  the  placenta. 

Schmorl  and  Kockel.197  Case  1.  Woman,  aged  twenty-six  years,  in 
seventh  or  eighth  month  of  pregnancy,  died  of  chronic  tuberculosis  and 
miliary  tuberculosis.  Child,  removed  by  cesarean  section,  lived  two 
hours.  No  histological  changes  of  tuberculosis  or  tubercle  bacilli  found 
in  fetus.  Placenta  appeared  normal  to  the  naked  eye.  Numerous  tubercle 
bacilli  found  in  smears  from  the  placenta.  Animal  inoculation  was  nega- 
tive. On  microscopic  examination,  placenta  showed  typical  tubercles 
in  all  stages.  Tubercle  bacilli  in  large  numbers  were  demonstrated. 
Case  2.  Mother,  aged  twenty-five,  died  of  general  miliary  tuberculosis. 
Fetus  removed  at  autopsy.  No  evidence  of  tuberculosis  in  fetal  organs. 
Typical  tubercles  containing  bacilli  found  in  the  placenta.  Case  3. 
Woman,  aged  thirty-three,  died  in  ninth  month  of  pregnancy  of  chronic 
pulmonary  tuberculosis.  The  child  was  removed  by  cesarean  section; 
dead  when  uterus  was  opened.  Male  child,  showed  nothing  suggestive 
of  tuberculosis.  No  tubercle  bacilli  found  in  fetal  tissues.  Placenta 
presented  no  naked  eye  appearances  of  tuberculosis.  Animal  inoculations 
with  fetal  tissue  were  negative.  Microscopically,  the  placenta  showed 
typical  tubercles  in  varying  stages,  not  so  numerous  as  in  cases  1  and  2. 
Tubercle  bacilli  were  present  in  large  numbers. 

Jung.197  Woman  showed  advanced  pulmonary  tuberculosis.  The 
placenta  presented  the  usual  histologic  picture  of  tuberculosis.  Tubercle 
bacilli  were  also  demonstrated.  Tuberculosis  was  not  present  in  the 
child. 

Warthin.198  Case  of  tubal  gestation  with  tuberculosis  of  tubes, 
placenta,  and  fetus.  Rupture  of  the  tubal  sac  in  fourth  month  ;  operation. 
Advanced  tuberculosis  of  tubes,  and  wall  of  sac.  Chorionic  villi  involved 
directly  by  extension  from  wall  of  tube.  Typical  tubercles  in  chorionic 
villi.    Few  tubercle  bacilli  found. 

In  one  of  fifty  successive  placentas  examined  at  the  Stadt  Kranken- 


y6         GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

haus  in  Dresden  (Schmorl's  laboratory)  miliary  tubercles  in  all  stages 
of  development  were  found  by  Warthin.  The  placenta  was  full  term. 
A  few  bacilli  were  demonstrated  in  it.  Nothing  was  known  of  mother 
or  child,  as  placenta  could  not  be  identified. 

Auche  and  Chambrelente.199     Mother,  far  advanced  in  tuberculosis, 
died  three  days  after  premature  delivery  in  seventh  month.     Placenta 
showed  numerous  caseous  tubercles  containing  tubercle  bacilli.     Inocula- 
tion of  guinea  pig,  positive.     Child  lived  twenty-six  days.     Autopsy , 
showed  extensive  tuberculosis. 

Wollstein.200  Mother  died  of  tuberculosis  six  days  after  birth  of  an 
eighth  month  child.  Placenta  measured  seventeen  centimeters  in  diam- 
eter and  three  millimeters  in  thickness.  It  contained  grayish,  yellowish, 
or  cheesy  nodules.  Histologically,  agglutination,  thrombi,  and  destruction 
of  the  syncytium  and  other  evidences  of  tuberculosis  were  present.  The 
umbilical  cord  was  normal.  The  uterine  mucosa  was  the  seat  of  a  tuber- 
culous deciduitis.  Tubercle  bacilli  were  demonstrated.  The  infant  lived 
nineteen  days.  No  tuberculosis  demonstrated  in  it.  This. case  was  one 
of  hematogenous  infection. 

Walther.201  A  patient  with  a  definite  family  history  of  tuberculosis 
died  in  the  seventh  month  of  pregnancy.  Macroscopically,  the  placenta 
showed  yellowish  white  patches  which  microscopically  proved  to  be  areas 
of  tuberculous  caseation  involving  the  decidual  portion  of  the  organ. 
These  lesions  affected  the  maternal  aspect  of  the  placenta  only.  Neither 
the  fetus  nor  the  umbilical  cord  showed  any  evidence  of  the  disease. 

Sitzenfrey 1X  reports  the  following  cases:  Case  I.  Patient,  aged 
twenty-eight  years  and  primipara,  had  a  spontaneous  delivery  of  a  male 
infant  which  measured  forty-one  centimeters  in  length  and  which  died 
after  four  hours.  The  mother,  who  had  a  history  of  slight  lung  trouble 
and  hemophesia,  rapidly  developed  symptoms  of  acute  miliary  tubercu- 
losis and  died  three  days  later.  Autopsy  showed  chronic  tuberculosis  of 
both  upper  lobes,  chronic  tuberculosis  of  the  peribronchial  lymph  glands, 
tuberculous  ulcer  of  the  larynx,  universal  miliary  tuberculosis,  and 
chronic  catarrh  of  the  large  and  small  intestines.  Autopsy  of  infant 
showed  total  fetal  atelectasis  of  lungs  and  multiple  ecchymoses  of  pleura 
and  pericardium.     No  tuberculosis  found  in  the  infant. 

The  placenta  measured  fourteen  centimeters  in  diameter  and  two 
centimeters  and  a  half  in  thickness.  It  weighed  3,300  grams,  and  showed 
no  gross  abnormalities  in  the  fresh  state.  After  hardening,  the  outer 
surface  showed  numerous  gray  red  to  yellow  or  whitish,  opaque  nodules, 
which  presented  the  appearance  of  the  little  infarcts  often  found  in  nor- 
mal placentas.    In  practically  all  sections  made  for  microscopic  examina- 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  77 

tion,  there  were  found  numerous  foci  of  caseation  and  round  cell  infil- 
tration, in  the  decidua  basalis,  in  the  villi,  on  the  edge  of  the  infarcts, 
and  in  the  chorionic  membrane.  In  these  areas  numerous  tubercle  bacilli, 
also  small  nodules  containing  tubercle  bacilli,  were  found  in  the  lumen 
of  veins  in  the  decidua  basalis.  These  foci  of  round  cell  infiltration  are 
not  characteristic  of  tuberculosis  alone,  but  may  be  found  in  various 
other  conditions;  their  definite  diagnosis  as  tuberculous  is  dependent 
upon  the  demonstration  of  tubercle  bacilli.  In  some  areas  these  in- 
flammatory foci  with  tubercle  bacilli  could  be  seen  to  have  broken  into 
the  intervillous  spaces.  Numerous  tubercles  of  various  types  are  pres- 
ent in  the  villi.  The  tubercle  bacilli  apparently  work  their  way  into 
the  syncytial  covering  of  the  villi  and  injure  it;  the  syncytium  becomes 
swollen,  loses  part  of  its  staining  properties,  and  contains  vacuoles,  in 
which  the  tubercle  bacilli  are  found.  As  a  result  of  this  process,  the 
syncytium  loses  its  power  of  preventing  blood  coagulation,  causing 
thrombotic  deposits  to  be  formed  on  the  surface  of  the  villus,  contain- 
ing numerous  leukocytes.  Under  the  influence  of  the  tubercle  bacillus 
these  masses  caseate;  new  areas  of  coagulation  are  formed  which  in- 
volve surrounding  villi,  and  in  turn  succumb  to  tuberculous  destruction, 
often  earlier  than  the  villus  which  formed  the  first  nidus  for  the  bacilli. 

No  tuberculosis  was  found  in  the  umbilical  cord  in  this  case.  One 
tubercle  bacillus  was  found  in  the  lumen  of  a  vessel  in  a  villus,  hence 
the  author  believes  it  probable  that  bacilli  had  reached  the  fetus,  although 
microscopic  examination  of  various  organs  was  entirely  negative.  He 
thinks  the  toxic  effect  of  the  metabolic  products  of  the  tubercle  bacilli 
was  the  underlying  cause  of  the  death  of  the  fetus  four  hours  post 
partum. 

Case  2.  Patient,  aged  thirty-four  years,  had  induction  of  labor  on 
account  of  pulmonary  and  laryngeal  tuberculosis.  The  male  infant 
weighed  2,150  grams.  The  child  was  immediately  removed  from  the 
mother  and  placed  in  an  orphanage.  Blood  from  the  umbilical  cord 
collected  and  injected  into  a  guinea  pig,  which  remained  healthy  and  on 
being  killed,  showed  no  signs  of  tuberculosis.  The  placenta  measured 
sixteen  centimeters  in  diameter,  weighed  480  grams,  and  macroscopically 
showed  no  pathologic  changes.  The  mother  did  well  for  a  time,  but  died 
about  four  months  post  partum  with  symptoms  of  peritonitis.  Autopsy 
showed  chronic  pulmonary  tuberculosis,  chronic  tuberculosis  of  the 
trachea,  larynx,  and  of  cervical  and  peribronchial  lymph  nodes,  chronic 
tuberculosis  of  the  intestines  with  perforated  ulcer  in  the  ileum:  one 
half  a  liter  of  fecal  fluid  was  found  in  the  peritoneal  cavity.  Tubercles 
were  found  in  the  liver,  kidney,  uterus,  and  tubes.     The  endometrium 


78  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

showed  caseous  areas  and  tubercles.     The  walls  of  the  tubes  were  thick- 
ened in  places  and  reduced  to  caseous  masses. 

The  child  died  at  the  end  of  three  months.  Autopsy  showed  chronic 
tuberculosis  of  both  lungs  with  pleuritis,  chronic  tuberculosis  of  the 
peribronchial  lymph  glands,  extensive  tuberculous  ulceration  of  the  large 
and  small  intestines,  tuberculosis  of  the  mesenteric  glands,  miliary  tuber- 
culosis of  the  liver,  spleen,  kidneys;  a  few  whitish  nodules  in  the  fossa 
of  Sylvius,  suggestive  of  tubercles. 

The  placenta  was  cut  into  slices  and  thirty  blocks  studied  histolog- 
ically. In  only  three  of  these  were  tuberculous  changes  found.  Although 
very  few  foci  were  present,  some  of  these  were  fairly  large,  involving 
decidua  basalis  and  villi.  No  bacilli  were  found  in  vessels.  Sitzenfrey 
believes,  however,  that  probably  the  bacilli  got  into  the  fetal  circulation. 
In  many  cases  the  peripheral  capillaries  of  the  villi  were  engorged  to 
bursting  point,  and  in  some  places  have  actually  burst,  permitting  ma- 
ternal and  fetal  blood  to  mix.  This  congestion  may  have  been  due  to 
pressure  on  the  umbilical  cord  by  the  bag  which  was  introduced  to  induce 
labor.  Microscopic  examination  of  the  umbilical  cord  for  tubercle  bacilli 
was  negative. 

There  was  no  possibility  of  a  postpartum  infection  of  the  child. 
Every  precaution  was  taken  in  the  institution  under  charge  of  Dr.  Ep- 
stein. It  seems  justifiable  to  conclude,  therefore,  that  the  tubercle  bacilli 
were  introduced  into  the  child  in  utero  or  during  delivery,  probably  the 
former.     The  case  was  probably  one  of  congenital  tuberculosis. 

Case  3.  Patient,  aged  thirty-two  years,  tripara.  (Previous  children 
healthy.)  She  was  delivered,  by  forceps,  of  a  male  infant  that  weighed 
2,520  grams.  It  was  sent  immediately  to  Dr.  Epstein's  institution.  The 
mother  died  three  weeks  post  partum.  Autopsy  showed  chronic  pul- 
monary tuberculosis,  tuberculosis  of  the  peribronchial  glands,  tuberculous 
ulcers  of  the  larynx,  trachea,  intestines,  chronic  tuberculosis  of  the  liver, 
spleen,  and  kidneys.  The  child  was  living  and  well  five  months  after 
birth. 

The  placenta  measured  seventeen  centimeters  by  eighteen  and  weighed 
570  grams.  Some  material  from  the  placenta  was  injected  into  the 
abdomen  of  a  guinea  pig,  which  became  very  ill ;  the  right  inguinal 
glands  swelled  to  the  size  of  a  pigeon's  egg,  but  the  animal  gradually 
recovered  and  the  swelling  disappeared.  Autopsy  showed  no  pathologic 
conditions.  Only  after  very  careful  searching  was  the  first  tuberculous 
focus  found  histologically;  this  was  an  infarct,  in  whose  periphery  round 
cell  infiltration  and  tubercles  in  villi  were  found;  many  tubercle  bacilli 
and  Langhans'  giant  cells  were  present.     Notwithstanding  this,  positive 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  79 

histologic  findings  and  animal  inoculations  were  negative ;  this  was  prob- 
ably due  to  the  fact  that  the  portions  of  tissue  used  happened  to  be  free 
from  tubercle  bacilli.  This  case  shows  that  not  only  is  a  negative  inocu- 
lation result  no  proof  of  the  freedom  of  the  placenta  from  tuberculosis, 
but  also  that  a  normal,  tubercle  bacilli  free  child  may  be  born  with  a 
tuberculous  placenta. 

Case  4.  Patient,  aged  twenty-five  years  and  bipara,  was  spontane- 
ously delivered  of  a  male  infant,  which  weighed  2,570  grams.  The  child 
was  not  separated  from  its  mother  and  died  one  month  after  birth.  Au- 
topsy showed  chronic  gastric  intestinal  catarrh,  icterus  universalis.  The 
mother,  at  the  time  of  delivery,  had  tuberculous  ulcers  on  both  tonsils 
and  involvement  of  both  apices.  The  placenta  measured  eighteen  centi- 
meters by  twenty  and  weighed  680  grams.  A  false  knot,  the  size  of  a 
hazel  nut,  was  found  in  the  umbilical  cord  near  the  placental  attachment. 
Microscopic  examination  of  this  showed  the  swelling  to  be  due  chiefly 
to  the  presence  of  inflammatory  infiltration  in  the  vessel  walls  and  sur- 
rounding jelly  of  Wharton.  The  veins  were  more  involved  than  the 
arteries.  In  the  intima  of  the  veins,  in  the  midst  of  this  inflammatory 
tissue,  a  group  of  three  tubercles  was  found;  in  one  of  these  was  a 
typical  giant  cell  with  two  tubercle  bacilli.  Numerous  other  scattered 
giant  cells  without  bacilli  were  found  in  the  walls  of  the  veins  and 
arteries.  Examination  of  the  placenta  showed  a  similar  round  cell  in- 
filtration in  the  walls  of  the  larger  vessels,  but  no  tubercle  bacilli.  Only 
a  few  pieces  of  placental  tissue  were  examined,  however,  as  the  remainder 
was  lost. 

Case  5.  Patient,  aged  twenty-nine  years  and  septipara,  had  four  chil- 
dren who  were  living  and  well.  Induction  of  labor  in  the  eighth  month  on 
account  of  the  condition  of  the  patient.  Male  premature  infant  which 
weighed  1,160  grams  and  died  in  four  hours.  Autopsy  showed  debilitas 
congenita  vitae  and  partial  atelectasis.  The  mother  died  three  weeks  post 
partum.  Autopsy  showed  chronic  pulmonary  tuberculosis,  chronic  sero- 
fibrinous pleuritis,  chronic  tuberculosis  of  the  peribronchial  and  cervical 
lymph  glands,  chronic  tuberculosis  of  the  larynx,  tuberculous  ulcers  of  the 
small  intestine,  and  chronic  tuberculosis  of  the  mesenteric  glands.  Three 
guinea  pigs  were  injected;  one  with  blood  from  the  umbilicus,  negative; 
one  with  material  from  fetal  organs,  negative ;  one  with  material  from  a 
yellow  white  nodule  from  the  maternal  surface  of  the  placenta,  a  smear 
preparation  from  which  had  shown  a  few  tubercle  bacilli.  This  animal 
developed  general  tuberculosis.  No  tubercle  bacilli  were  found  upon 
histologic  examination  of  the  placenta,  but  one  bacillus  was  found  against 
the  internal  surface  of 'the  wall  of  a  vein  in  the  decidua  basalis.     No  tu- 


8o  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

bercle  bacilli  were  found  upon  histologic  examination  of  the  fetal  organs, 
bone,  marrow,  or  lymph  glands,  although  numerous  acid  fast  bacilli 
were  present  in  these  organs;  however,  their  morphology  did  not  cor- 
respond to  that  of  the  tubercle  bacillus.  (Probable  contamination.) 
There  were,  nevertheless,  marked  changes  found  in  the  lymphatic  sys- 
tem— enormous  dilatation  of  sinuses  of  the  lymph  glands;  enlargement 
of  afferent  and  efferent  lymph  vessels,  This  condition  suggests  the  pos- 
sibility of  circulatory  disturbances  of  the  placenta,  or  may  perhaps  be 
due  to  the  presence  of  toxic  substances — bacterial  toxins  which  have  been 
transmitted  from  mother  to  child. 

Case  6.  Patient,  aged  twenty-eight  years  and  bipara,  had  had  two 
miscarriages.  Induction  of  labor  as  in  preceding  case.  Dead  female  child 
weighed  1,370  grams.  The  patient  showed  advanced  laryngeal  tuber- 
culosis, involvement  of  the  left  pulmonary  apex.  Autopsy  of  child 
showed  atelectasis  of  lungs  of  premature  infant.  Several  cubic  centi- 
meters of  umbilical  cord  blood  were  injected  into  two  guinea  pigs  at 
time  of  delivery,  and  several  cubic  centimeters  of  salt  solution  extract 
of  the  placenta  into  two  others.  In  about  three  months  the  animals  be- 
came ill;  killed  after  four  months  and  all  showed  extensive  tuberculous 
lesions.  Histologic  examination  of  the  placenta  and  umbilical  cord  was 
negative;  the  same  result  with  the  fetal  lungs,  thymus,  spleen,  kidneys, 
adrenals,  stomach,  intestines,  inguinal  and  peribronchial  lymph  glands. 
A  tubercle  bacillus  was  found  in  the  adenoid  tissue ;  in  one  retroperito- 
neal gland,  a  bacillus  was  found  in  the  lumen  of  a  dilated  lymph  sinus. 
No  tubercles  or  giant  cells. 

The  infection  of  the  lymph  nodes  must  have  occurred  by  one  of  two 
routes — either  directly  by  means  of  emboli,  or  indirectly  through  the 
lymph.  The  latter  is  probably  the  more  important.  It  is  quite  possible, 
as  numerous  authors  have  demonstrated,  for  tubercle  bacilli  to  lie  dor- 
mant in  the  lymph  glands  for  a  considerable  time  without  causing  typical 
lesions.  In  this  case,  the  fact  that,  notwithstanding  the  presence  of 
tubercle  bacilli  in  the  circulation  and  in  the  lymph  glands,  there  was  no 
evidence  of  tuberculous  changes  in  the  organs  of  the  fetus,  may  be  ex- 
plained on  the  theory  that  infection  had  occurred  just  before  birth,  and 
that  bacteria  had  not  had  time  to  cause  lesions ;  but  Sitzenf  rey  is  inclined 
to  apply  here  Bail's  aggressin  theory — invasion  of  the  fetus  occurred 
only  after  it  had  acquired  from  the  previously  received  tuberculosis  ag- 
gressins  an  immunity,  whereby  it  was  in  a  position  to  resist  infection 
and  either  destroy  completely  the  tubercle  bacilli,  or  force  them  into  a 
long  period  of  latency. 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  81 

TUBERCLE  BACILLI  IN  FETUS  AND  PLACENTA  WITH- 
OUT HISTOLOGICAL  CHANGES 

Undoubted  Cases. — Diagnoses  rest  upon  the  demonstration  of  the 
bacilli  by  staining  or  by  inoculation  of  animals. 

Warthin  and  Cowie.12  Woman  in  fifth  month  of  pregnancy,  with 
chronic  tuberculosis  of  kidney  and  general  miliary  tuberculosis;  abortion; 
death;  tuberculous  thrombosis  of  placental  sinus  and  intervillous  spaces; 
tuberculosis  of  placenta;  tuberculous  thrombi  in  fetal  blood;  presence  of 
free  tubercle  bacilli  in  fetal  circulation,  with  histologic  changes. 

Leuenberger  202  reports  two  cases  of  acute  miliary  tuberculosis  of 
the  mother,  in  which  miliary  tubercles  were  found  in  the  placenta.  Tu- 
bercle bacilli  were  present  in  the  fetal  circulation.  There  were  evidences 
of  injury  to  the  placental  blood  vessels. 

Landouzy  and  Martin.203  Mother  died  of  tuberculosis  in  the  fifth 
month  of  pregnancy.  Portions  of  the  placenta  and  twenty-five  drops  of 
blood  from  the  fetal  heart,  inoculated  into  three  guinea  pigs,  produced 
tuberculosis  in  the  latter  in  four  months.  Three  other  guinea  pigs  inocu- 
lated with  portions  of  the  fetal  liver,  lung,  and  brain,  respectively,  were 
negative  for  tuberculosis. 

Landouzy  and  Martin.203  A  portion  of  the  lung  of  the  six  and  a 
half  months  fetus  of  a  tuberculous  mother,  dying  a  few  days  after  de- 
livery, was  inoculated  into  the  peritoneal  cavities  of  guinea  pigs.  The 
animals  died  of  general  tuberculosis  four  months  afterward. 

Huguenin.204  A  woman  of  thirty-six  years  of  age  died  of  advanced 
phthisis  florida  during  the  sixth  month  of  pregnancy.  Tubercle 
bacilli  had  been  present  in  the  sputum.  An  autopsy  showed  the  usual 
characteristics  of  this  disease  and  tubercle  bacilli  were  recovered  from 
the  blood.  The  uterus  was  enlarged,  rising  as  high  in  the  abdomen  as 
the  umbilicus.  The  placenta  and  child  were  macroscopically  normal,  but 
tubercle  bacilli  were  recovered  from  the  fetal  blood. 

Charron  and  Karth.205  Guinea  pig  inoculated  with  portions  of 
placenta  from  tuberculous  mother.  The  result  was  positive.  No  tuber- 
culosis was  demonstrated  in  the  child. 

Herrgott.103  Woman  dying  of  chronic  pulmonary  tuberculosis  in 
sixth  month  of  pregnancy.  Inoculation  of  guinea  pigs  with  amniotic 
fluid  was  positive.     This  is  the  first  case  of  the  kind  recorded. 

Schmorl  and  Birch-Hirschfeld.124  Seven  months  fetus  removed  by 
cesarean  section  from  mother,  twenty-three  years  of  age,  dying  of  miliary 
tuberculosis.     Tubercle  bacilli  found  in  the  fetal  liver,  in  intervillous 


82    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

spaces,  and  in  chorionic  villi.  No  histologic  changes  of  tuberculosis  were 
observed.  Inoculation  of  guinea  pigs  with  portions  of  fetal  liver  were 
positive. 

Landouzy.206  Case  i.  The  seven  months'  fetus  of  a  tuberculous 
mother  showed  no  histologic  changes.  Inoculation  of  guinea  pig  with 
portions  of  fetal  organs  gave  positive  results.  Case  2.  The  five  months 
fetus  of  mother  dying  of  tuberculosis  presented  no  histologic  changes. 
Placenta  apparently  normal.  Inoculations  with  portions  of  placenta  and 
heart  blood  of  fetus  were  positive;  inoculations  with  fetal  liver,  doubt- 
ful; inoculations  with  portions  of  lung  and  brain  were  negative. 

Aviragnet.207  The  seven  months  fetus  of  mother  dying  of  acute 
miliary  tuberculosis  showed  no  histologic  changes.  Tubercle  bacilli  were 
demonstrated  in  the  fetal  blood.  Inoculation  of  guinea  pig  with  por- 
tions of  placenta  and  fetus  gave  positive  results.  This  case  is  somewhat 
similar  to  the  one  of  Schmorl  and  Birch-Hirschfeld. 

Thiercelin  and  Londe.208  Mother  died  of  pulmonary  and  intestinal 
tuberculosis  fourteen  days  after  delivery.  Child  died  on  fourth  day. 
Numerous  tubercle  bacilli  were  found  in  the  fetal  liver,  spleen,  and  kid- 
neys. No  histologic  changes  found.  Inoculations  of  guinea  pigs  with 
blood  from  umbilical  cord  were  positive. 

Londe.209  Case  1.  Mother  died  of  acute  miliary  tuberculosis  eight 
days  after  abortion.  No  tuberculous  changes  of  tubercle  bacilli  were 
found  in  the  fetus.  Inoculations  of  guinea  pigs  with  portions  of  liver 
and  placenta,  and  with  fetal  blood,  were  positive.  Case  2.  Mother  died 
with  advanced  tuberculosis.  Infant  died  ten  days  after  birth.  No 
macroscopic  or  histologic  evidence  of  tuberculosis  was  found  in  the  fetus. 
Guinea  pig  inoculations  with  venous  blood,  portions  of  fetal  organs,  and 
placenta  were  positive. 

Schmorl  and  Kockel 196  report  three  cases  of  abortion  in  mothers 
suffering  from  general  tuberculosis.  No  histologic  changes  were  found 
in  the  fetus  in  any  one  of  the  cases.  In  one  case  tubercle  bacilli  were 
found  in  the  fetal  liver,  periportal  tissue,  and  lymph  glands  by  staining 
methods.  The  placenta  in  each  case  contained  bacilli  and  tubercles. 
The  inoculation  with  portions  of  fetal  organs  was  negative  in  all  three 
cases. 

Bugge.162  Eight  months  fetus  of  mother  with  miliary  tuberculosis 
lived  but  thirty  hours  after  birth.  Mother  died  shortly  afterward.  Tu- 
bercle bacilli  were  found  in  the  blood  from  the  umbilical  vein  and  in 
the  liver  vessels.  No  histologic  changes  found.  Three  guinea  pigs  in- 
oculated with  blood  from  the  umbilical  vein.  Portions  of  fetal  liver  and 
lung  gave  positive  results. 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  83 

Londe.209  The  mother  died  of  tuberculosis  ten  days  after  delivery. 
No  autopsy  was  performed,  but  the  diagnosis  was  beyond  doubt.  Por- 
tions of  the  placenta  were  inoculated  into  guinea  pig.  The  animal  sub- 
sequently died  of  tuberculosis.  The  infant  died,  but  no  autopsy  was 
obtained. 

Doleris  and  Bourges.210  Mother  died  of  acute  miliary  tuberculosis 
three  weeks  after  delivery  of  a  seven  months  child.  The  marasmic  infant 
died  five  weeks  after  birth.  No  tubercle  bacilli  or  histologic  changes  of 
tuberculosis  found  in  child  by  staining  methods.  The  inoculation  of  a 
guinea  pig  with  the  heart  blood  of  the  child  gave  a  positive  result.  The 
fact  that  the  child's  blood  should  contain  bacilli  for  five  weeks  without 
occurrence  of  tissue  changes  is  most  remarkable.  The  case  is  doubted 
by  Hauser  and  Cornet. 

Kynoch.211  Patient  aged  twenty-eight  years  and  primipara.  She 
had  symptoms  of  rapidly  advancing  phthisis  for  six  weeks.  Fever  of 
1020  F.  She  was  three  months  pregnant.  Death  occurred  from  tuber- 
culosis. Postmortem  showed  macroscopic  lesions  resembling  tuberculosis 
(nodules)  in  the  lungs,  liver,  and  peritoneum.  The  adnexa  were  ad- 
herent, but  the  tubes  were  patulous.  The  placenta  was  studied  with 
gray,  non-caseous  tubercles.  The  fetus  was  macroscopically  normal.  No 
histologic  or  bacteriologic  examination  was  reported. 

Armanni.212  Mother  died  of  tuberculosis  in  seventh  or  eighth  month 
of  pregnancy.  Fetus  showed  no  histologic  changes.  Portions  of  spleen, 
liver,  and  brain  were  inoculated  into  two  guinea  pigs.  One  died  four 
months  afterward  of  general  tuberculosis;  the  other  not  affected.  Sec- 
ondary infection  of  pig  not  excluded. 

Thiercelin  and  Londe.208  Mother  died  fourteen  days  after  delivery. 
Had  pulmonary  and  intestinal  tuberculosis.  Child  died  a  few  days  after 
birth.  No  autopsy.  A  portion  of  the  placenta  was  placed  in  the  peri- 
toneal cavity  of  guinea  pig  and  gave  positive  result.  Actual  condition 
of  child  not  known. 

Bar  and  Renon.84  Five  cases  of  tuberculous  mothers.  The  blood 
of  umbilical  vein  was  injected  immediately  into  guinea  pigs.  Three 
cases  gave  negative  results;  two  were  positive.  Of  the  latter,  one  case 
showed  no  apparent  lesions  in  placenta  and  fetus,  and  no  tubercle  bacilli 
could  be  demonstrated  by  staining  methods.  Mother  was  in  the  last  stage 
of  pulmonary  tuberculosis.  Three  animals  were  inoculated  with  pieces 
of  liver  and  lung  and  with  peritoneal  fluid.  The  ones  inoculated  with 
portions  of  liver  and  lung  tissue  had  general  tuberculosis;  the  one  inocu- 
lated with  peritoneal  fluid  had  tuberculosis  of  spleen. 

Case  2.     This  case  is  open  to  grave  doubt,  as  secondary  infection 


84  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

was  not  excluded.  Mother  had  tuberculous  cavities  in  lungs.  Child 
died  of  bronchopneumonia  on  the  fortieth  day  after  birth.  Placenta 
appeared  normal.  Two  guinea  pigs  were  inoculated  with  blood  from 
umbilical  vein ;  one  was  negative ;  the  other  developed  local  and  gen- 
eral tuberculosis. 

Bolognesi.213  Portions  of  13  placentas  from  tuberculous  women, 
and  in  a  few  cases  portions  of  the  fetus  also,  were  examined  for  tubercle 
bacilli.  In  eight  cases  in  which  the  fetus  was  examined  histologically 
and  animals  inoculated,  no  histologic  changes  were  found.  In  only  one 
case  the  inoculation  with  placenta  was  positive.  The  report  is  inexact 
and  contradictory. 

Henke.214  Mother  had  chronic  tuberculosis.  Child  died  four  days 
after  delivery.  Autopsy  showed  pneumonia  with  fresh,  fibrinous  pleuri- 
tis.  No  microscopic  changes  of  tuberculosis.  Portions  of  an  appar- 
ently healthy  bronchial  gland  were  inoculated  into  guinea  pigs.  The 
pig  showed  general  tuberculosis  on  the  thirty-seventh  day.  Neither 
histologic  changes  nor  tubercle  bacilli  could  be  found  in  serial  sections 
of  another  gland.  Henke  excludes  accidental  infection  of  inoculated 
animal  and  regards  case  as  a  typical  tuberculosis  inoculation. 

Kurbitz  215  reports  a  case  of  tuberculosis  of  the  decidua  basalis  from 
the  Marburg  Pathological  Institute.  The  patient  suffered  from  chronic 
pulmonary  and  laryngeal  tuberculosis  and  died  three  days  after  a  confine- 
ment in  the  eighth  month.  The  child  weighed  only  1,880  grams  and  was 
delicate.  It  showed  no  signs  of  tuberculosis  and  was  negative  to  the 
tuberculin  reaction.  It  died  at  three  months  of  age  from  volvulus,  and 
autopsy  showed  no  signs  of  tuberculosis.  The  autopsy  in  the  mother 
showed  the  lungs  and  larynx  involved  and  several  small  ulcers  near  the 
ileocecal  valve  and  tubercles  in  the  liver.  At  the  placental  site  was  a  dark 
red  blood  clot  to  which  numerous  red  thrombi  were  attached.  Macro- 
scopically  this  did  not  show  disease,  but  under  the  microscope  typical 
tuberculosis  was  present.  The  superficial  zone  of  the  placental  site  was 
thickly  crowded  with  miliary  tubercles.  These  did  not  appear  to  have 
penetrated  any  vessels,  although  in  many  areas  they  were  actually 
approximated  to  the  vessel  wall.  The  thrombi,  which  were  numerous, 
did  not  in  themselves  show  tuberculosis,  nor  was  there  any  marked  in- 
flammation in  the  basal  decidua.  Tubercle  bacilli  were  demonstrated 
in  the  membranes.    The  placenta  proper  could  not  be  investigated. 

Rielander  and  Mayers.216  The  patient  was  twenty  years  of  age  and 
had  been  suffering  from  pulmonary  phthisis  for  some  years.  At  the 
time  of  admittance  to  the  hospital,  the  sputum  contained  numerous  typical 
tubercle  bacilli.    The  disease  was  progressing  rapidly.    A  vaginal  hyster- 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  85 

ectomy  was  performed.  Death  followed.  The  decidua  presented  a  well 
marked  tuberculous  inflammation,  and  tuberculosis  of  placenta  was  also 
present.    Tubercle  bacilli  were  demonstrated  by  the  Ziehl-Neelson  stain. 


CONCLUSIONS 

Congenital  Tuberculosis. — 1.  This  is  a  rare  condition;  a  number 
of  authentic  cases  have,  however,  been  recorded.  That  transplacental 
infection  is  most  likely  to  occur  in  the  last  few  weeks  of  pregnancy  and 
especially  as  a  result  of  uterine  contraction  during  labor,  together  with 
the  well  known  latency  of  tuberculosis,  are  facts  which  are  suggestive 
that  this  variety  of  infection  may  in  some  instances  be  mistaken  for  a 
postnatal  infection. 

2.  As  a  result  of  congenital  infection,  the  liver  and  adjacent  struc- 
tures, especially  the  lymph  glands,  are  the  localities  most  frequently 
attacked. 

3.  The  prognosis  in  the  congenitally  infected  is  unfavorable;  first, 
because  of  the  vital  character  of  the  organs  usually  involved;  and  sec- 
ondly, owing  to  the  virulent  type  of  organism  usually  present,  maternal 
bacillemias  rarely  being  found,  except  in  a  virulent  type  of  infection. 

4.  For  a  congenital  hemogenic  infection  to  occur,  a  maternal  bacil- 
lemia  and  a  permeability  of  the  placenta  must  precede  the  condition. 

5.  Whether  tubercle  bacilli  can  be  transmitted  through  the  normal 
placenta  is  still  undetermined ;  certainly,  when  lesions  are  present  the 
placenta  cannot  be  regarded  as  a  secure  filter. 

6.  Preexisting  lesions  in  the  placenta,  especially  those  produced  by 
syphilis,  are  predisposing  factors  to  the  transmission  of  tubercle  bacilli. 

7.  Lesions  in  the  placenta  may  be  produced  by  the  tubercle  bacilli 
themselves,  which  may  result  in  conditions  favoring  the  transmission  of 
organisms  to  the  fetal  circulation. 

8.  The  presence  of  tubercle  bacilli  in  the  placenta  is  undoubtedly  of 
more  frequent  occurrence  than  was  formerly  believed,  and,  in  view  of 
the  results  obtained  by  recent  investigations,  a  more  thorough  study  of 
the  question  of  the  frequency  of  congenital  tuberculosis  is  desirable. 

9.  Until  a  fairly  large  series  of  fetuses  and  newly  born  infants  can 
be  thoroughly  studied  by  carefully  performed  histologic  and  inoculation 
methods  the  relative  frequency  of  this  type  of  infection  cannot  be  de- 
termined. 

10.  The  presence  of  tubercle  bacilli  in  the  placenta  by  no  means  in- 
fers a  congenital  infection,  but  is  undoubtedly  a  predisposing  agent. 


86  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

ii.  Congenital  tuberculosis  can  be  experimentally  produced  in  ani- 
mals, but  only  in  a  small  percentage  of  cases,  and  even  then  as  a  rule  only 
by  the  injection  into  the  mother  of  what  are  relatively  enormous  quan- 
tities of  a  pure  culture  of  tubercle  bacilli.  Such  results  can  hardly  be 
compared  with  what  occurs  in  the  pregnant  tuberculous  woman. 

12.  Animal  inoculation  is  the  most  reliable  method  of  testing  for 
the  presence  of  tubercle 'bacilli,  either  in  the  placenta  or  fetus. 

13.  The  animals  should  be  tested  with  tuberculin  before  inoculation 
and  carefully  guarded  from  possible  extraneous  infection  subsequently 
to  injection. 

14.  As  an  additional  safeguard,  a  second  series  of  animals  should 
be  inoculated  from  those  dead  of  the  primary  injection.  This  should 
be  performed  for  the  purpose  of  positively  determining  the  virulence  of 
the  microorganisms,  as  it  is,  at  least  theoretically,  possible  that  dead 
tubercle  bacilli  might  be  present.  This  precaution  was  adopited  in 
many  of  our  cases,  and  in  all  in  which  there  was  the  least  ground  for 
doubt.     It  was  positive  in  all  cases. 

15.  Whereas  the  antiformin  method  is  of  value,  the  acceptance  of 
one  or  two  acid  fast  bodies  morphologically  similar  to  the  tubercle  bacil- 
lus demonstrated  in  a  large  series  of  slides  is  unreliable. 

16.  In  certain  types  of  maternal  tuberculosis,  tubercle  bacilli  are  not 
infrequently  present  in  the  placenta.  Undoubtedly  the  most  frequent 
period  at  which  transplacental  infection  occurs  is  during  labor;  for  this 
reason  the  umbilical  cord  in  these  cases  should  be  tied  as  soon  as  pos- 
sible, certainly  without  waiting  for  the  pulsation  to  cease. 

17.  The  child  should  be  taken  away  from  the  mother  immediately 
and  carefully  guarded  against  postnatal  infection. 

Placental  Tuberculosis. — 1.  Placental  tuberculosis  may  result 
from  the  infection  of  the  spermatozoon  or  ovum.  This  assumption  is 
based  upon  theoretic  grounds  only  and  such  an  instance  is  probably  ex- 
tremely rare,  too  rare  to  have  much  practical  importance. 

2.  Placental  tuberculosis  may  result  from  a  direct  extension  from 
a  nearby  focus,  such  as  a  preexisting  endometritis.  This  also  is  prob- 
ably a  comparatively  rare  variety. 

3.  Placental  tuberculosis  may  result  from  a  hemogenic  infection. 
This  is  the  most  frequent  variety.  It  requires  a  maternal  bacillemia,  a 
condition  which  in  itself  is  comparatively  infrequent. 

4.  Bacillemias  are  most  frequently  present  in  the  acute  miliary  form 
of  tuberculosis;  when  ulcerative  lesions  break  into  adjacent  blood  vessels; 
when  hyperpyrexia  is  present — a  condition  which  tends  to  impair  the 
integrity  of  the  blood  vessels;  and  during  acute  exacerbations  of  the 


•  CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  87 

disease.  It  is  worthy  of  note  that,  in  the  tuberculous  woman,  pregnancy 
frequently  produces  an  exacerbation  of  the  disease  and  results  in  con- 
ditions favorable  for  the  production  of  a  bacillemia. 

5.  Tubercle  bacilli  are  frequently  present  in  the  placenta  without 
macroscopic  lesions,  as  proven  by  our  own  investigations  and  those 
of  others.  This  is  a  much  more  frequent  condition  than  are  actual  macro- 
scopic lesions. 

6.  Tubercle  bacilli,  when  found  in  the  placenta,  are  frequently  viru- 
lent. 

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35.  Walther,  H.    Ziegler's  Beitr.     1894.     16:274. 

36 
37 


38 
39 
40 

4i 

42 

43 

44 

45 
46 

47 

48 


Gartner,  A.    Ztschr.  f.  Hyg.  u.  Inf.     1893.     13:101. 

Cornet,  G.    Tuberculosis.    Philadelphia,  New  York,  and  London. 

1904. 
Friedman,  F.    Deuts.  Med.  Woch.    1901.    27:129. 
Varaldo,  F.  R.     Clin.  obst.     Jan.  15,  1906. 
Schottlander,  J.    Monschr.  f.  Geburt.  u.  Gyn.     1897.    v.  5. 
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1906.     Springer. 
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1896.     i43:559- 
Bab.    Deuts.  Med.  Woch.     1906.    No.  48. 
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Simmonds.    Munch.  Med.  Woch.     1906.    No.  2j. 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  89 

49.  Hollos,  J.     Virch.  Arch.     1913.     213:  No.  2,  3. 

50.  Rosenau  and  Anderson.     Jr.  Amer.  Med.  Assoc.    1908.   p.  961. 

51.  Huppe,  F.     Inaug.  Dis.     Rostock,  1902. 

52.  Bartel,  S.    Wien.  Klin.  Woch.     1905,  No.  34,  41 :  1906,  No.  16 : 

1907;  1908,  No.  22. 

53.  Klebs,  E.    Munch.  Med.  Woch.     1901.    p.  129. 

54.  Carriere,  G.     Centrbl.  f.  In.  Med.  1901.     p.  1017 

55.  Bossi.     Arch.  f.  Gyn.     1916.     77:21. 

56.  Pehu,  M.,  et  Chalier,  J.     Arch,  de  Med.  des  enf.     1915.     18: 

No.  1. 

57.  Rosenberger,  R.  C.     N.  Y.  Med.  Jr.    June  15,  1909. 

58.  Rump.     Munch.  Med.  Woch.     1912.     No.  36. 

59.  Liebermeister.     Med.  Klin.     1912.     No.  25. 

60.  Gurner,  E.    Munch.  Med.  Woch.     1913.    60:401. 

61.  Dressen.     Med.  Klin.     1913.     No.  13. 

62.  Gobel.    Deuts.  Med.  Woch.     191 3.    No.  24. 

63.  Klemperer.     Ther.  d.  Gez.     19 12.     No.   10. 

64.  Kahn,  E.     Munch.  Med.  Woch.     191 3.     60:345. 

65.  Kessler.     Munch.  Med.  Woch.     1913.    60:346. 

66.  Bacmeister.     Centrbl.  f.  d.  Grenzg.  d.  Med.  u.  Chir.    1913.    16: 

No.  5,  6. 
6y.     Vinogradoff.     Russky  vratch.     1914.     13 :  No.  22. 

68.  Fraenkel.     Deutsch.  Med.  Woch.    April  17,  19 13. 

69.  Elsasser,  J.     Beitr.  z.  Klin.  d.  Tuberk.     19 13.    26:  No.  4. 

70.  Bogason,  P.    Ugesk.  f.  Lag.     1913.     75  :  No.  18. 

71.  Calmette,  A.    Press  Med.    Feb.  7,  19 14. 

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des  Menschen  u.  d.  Tierre.  Wiesbaden,  1896,  J.  F.  Bergmann; 
also  Virch.  Arch.     124:4. 

73.  Schaudinn.     Arb.  a.  d.  Kais.  Geshtamt.     1907.     26:11. 

74.  Paschen.     Munch.     Med.  Woch.     1906.     p.  622. 

75.  Wallich    et    Levaditi.      Compt.    rend.    Soc.    de    Biol.      1906. 

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j6.  Menetrier  et  Rubeno-Duval.     Presse  Med.     1906.    p.  7. 

yy.  Neuhaus.     Bed.  Klin.  Woch.     1886.     p.  389. 

78.  Freund  und  Levy.     Berl.  Klin.  Woch.    June  2y,  1895. 

79.  Van  der  WiTTiGEN.    Ned.    Tijdschr.  v.  Geneesk.    1895.    No.  11. 

80.  Dorland,  W.  A.  N.    Am.  Jr.  Obst.  and  Gyn.    June,  1900. 

81.  Runge.     Arch.  f.  Gyn.     1903.     68:388. 

82.  Nattan-Larrier   et   Brindeau.      Compt.    rend.    Soc.   de  Biol. 

1906.    60:181. 


go  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

83.  Delestre.     Sem.  Med.     Feb.  9,  1898. 

84.  Bar  et  Renon.     Ann.  de  gyn.  et  d'obst.     1895.     44:217.     Also 

Rev.  de  la  tuberc.     1895.    p.  237.    Also  Compt.  rend,  de  la  Soc. 
de  Biol.     1895.     10:505. 

85.  Preyer,  W.     Physiologie  special  de  l'embryon ;  recherches  sur  les 

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86.  Savory.    Quoted  by  Preyer;  No.  85. 

87.  Fournier.     Sem.  Med.     Nov.  30,  1898. 

88.  Zwiefel.     x^rch.  f.  Gyn.     1877.    p.  235. 

89.  Jung,  P.    Ther.  Montschr.     1914.    28:  No.  2. 

90.  Waldeyer.    Arch.  f.  Mikr.  Anat.     1890.    35  :i. 

91.  Bumm.     Arch.  f.  Gyn.      1893.     43:181. 

92.  Leopold.     Verhl.  d.  Deutsch.  Gesel.  f.  Gyn.     1890.     3,  257. 

93.  Williams,  J.  W.     Johns  Hopkins  Hospital  Reports.     1893-94. 

3:87;  1 141. 

94.  Delore.     Jr.  de  Med.  de  Paris.,  April  16,  1899. 

95.  Warthin,  S.  A.     Jr.  Inf.  Dis.     1907.    4:347. 

96.  Warnekros.     Deutsch.  Gesel.  f.  Gyn.     May,  19 13. 

97.  Schmorl  und  Kockel.     Centrbl.  f.  Gyn.     1894      18:307 

98.  Asch.     Monschr.  f.  Gebh.  u.  Gyn.      1913.     27:701. 

99.  Leloir.     In  Verneuils  Etudes  sur  la  tuberculose.     1892.     3  .-482. 

100.  Baginsky,  B.     Berl.  Med.  Gesel.    Jan.  14,  1891. 

101.  Wasmuth,  B.    Centrbl.  f.  Bakt.     1892.    3:824. 

102.  Roth.    Ztschr.  f.  Hyg.    4:151. 

103.  Herrgott,  A.    Ann.  de  Gyn.  et  d'obst.     1891.     36:1. 

104.  Hochsinger,  S.  Wien.  Med.  Blat.     1894.     17:255. 

105.  Henle,  A.    Pseudotuberculose  bei  Neugeborenen  Zwillingen,  Orth. 

Festsch.  f.  Virchow.     1893.    p.  143. 

106.  Merlitti,  C.     Arch,  di  obst.  e.  gin.     1901.     p.  512,  649,  714. 

107.  Barkley,  C.    Jr.  Obst.  Gyn.  Brit.  Emp.     1903.     3:31. 
10S.     Ascoli.    Policlin.    1899.    Supp.  p.  370.    nach  Bossi. 

109.  Leyden,  E.  von.    Ztschr.  f.  Klin.  Med.     1884.     8:375. 

110.  Jaquet.     Quoted  by  Cornet,  No.  ^y. 

in.     Vignal,  W.     Deuxieme  cong.  pour  l'etude  de  la  tuberc.     Pans, 
1891.    p.  334. 

112.  Treisser.     Quoted  by  Straus;  No.  149. 

113.  Bernard,  Debrer,  and  Baron.     Quoted  by  H.  Dufour  and  J. 

Thiers  in  La  Gynecologic     19 13.    p.  400. 

114.  Bar  and  Renon.     Rep.  univ.  d'obst.  et  de  gyn.     Sep.,  1895. 

115.  Armann.    Fourth  Int.  Cong.  Obst.  and  Gyn.     Rome,  1904. 


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116.  Leroux,  L.     Tuberculose  du  premier  age  d'apres  les  observations 

indedites  du  Prof.  Parrot.     In  Verneuil's  Etudes  sur  la  tuber- 
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117.  Lannelongue,  O.  M.     Legons  de  Clinique  Chirurgicale,  Paris, 

1905 ;  also  Cong,  pour  l'etude  de  la  tuberculose,  Paris,  1889. 

118.  Muller,  D.     Munch.  Med.  Woch.      1899.     p.  875. 

119.  Haupt.    Deutsch.  Med.  Ztschr.     1891.    p.  997. 

120.  Hardy.     Bui.  Soc.  Anat.  de  Paris.     1834.     p.  115. 

121.  Charrin.     Lyon  Med.     1873.     p.  295. 

122.  Jacobi,  A.     Compt.   Rend.  2eme  Cong.  Tuberc.     Paris.     1891. 

2  1327. 

123.  Sabouraud,  R.     La  med.  Mod.  189 1.     2:749. 

124.  Schmorl    und    Birch-Hirschfeld.     Ziegler's  Beitr.     1891. 

9 1428. 

125.  Runge.    Centrbl.  f.  Gyn.     1884.    No.  48. 

126.  Klepp.    Ztschr.  f.  Fleisch.  u.  Milch.  Hyg.     1897.    7:67. 

127.  Malrox  et  Brouwier.     Ann.  Inst.  Past.     1889.     3:153.     1902. 

128.  Czoker.    Vers.  Deutsch.    Naturf.  u.  Arz.    Wien.     1894. 

129.  Bank.    Deutsch.  Ztschr.  f.  Thiermed.     1890.     16:409. 

130.  McFadyen,  Jr.    Comp.  Path.  Ther.     1891.    6:353. 

131.  Siegen,  C.     Cong.  f.  Erforsch  d.  Tuberc.  Paris,  3rd  Session. 

132.  Lungwitz.     Centrbl.  f.  d.  Med.  Wiss.     1894.    32:414. 

133.  v.  Nocard.     Ztschr.  f.  Fleisch.  u.  Milch.  Hyg.     1897.    7:98. 

134.  Grancher,  A.     Sem.  Med.     1886.     p.  297. 

135.  Kohler.     Siedamgrotzk'scher  Jhb.     1888-89. 

136.  Misselwitz.     Siedamgrotzk'scher  Jhb.     1888-89. 

137.  Bayersdorfer.     Mitt.  d.  Ver.  Bad.  Thieraz.     1892.    p.  55. 

138.  Becker.     Ztschr.  f.  Fleisch.  u.  Milch.  Hyg.     1895.     5:115. 

139.  Ruser.    Ziegler's  Beitr.     16:294. 

140.  Barland.     Baumgarten's  Jahrb.    9  749. 

141.  Galthier,  S.     Ann.  Inst.  Past.    2:492. 

142.  Bucher.     Ztschr.  f.  Fleisch.  u.  Milch.  Hyg.     1897.     7:217. 

143.  Lohoff.     Ztschr.  f.  Fleisch.  u.  Milch.  Hyg.     1897.     7:163. 

144.  Brooks,  H.     Proe.  Soc.  Exp.  Biol.  Med.     1914.     11:50. 

145.  Lodenih,  L.     Press,  med.     191 1.     No.  83. 

146.  Sanchez-Toledo.     Arch,  de  med.  exp.  et  d'anat.  path.     1889. 

1  -S03- 

147.  v.  Nocard.     Rev.  de  la  Tuberc.     1895.    p.  226;  also  Centrbl.  f. 

Bakt.     1896.     19:625. 

148.  Wolff,  M.     Virch.  Arch.     1886.     105:192;  v.   106:  also  Vir- 

chow's  Festsschr.     v.  3. 


92  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

149.  Straus,   I.     La  tuberculose  et  son  bacilli.     Paris,   1895,   Rueff 

and  Cie.     p.  545. 

150.  Carajnis.     Citti  del  Instit.    Veneto.     1885-86.     4:iJ45- 

151.  Feyerabend,    P.     Beitr.    z.    Klin,    der    Tuberk.      1914.     29: 

No.  1. 

152.  Eden,  N.  T.     Jr.  Path.  Bact.    1897.    5  1265,  282;  also  A  Manual 

of  Midwifery. 

153.  Lehmann,  F.     Berl.  Klin.  Woch.     1894.    31 :6oi. 

154.  Houl.     Bui.  Internat.  Acad.  Sc.     Prag.     1894. 

155.  Ustinow,  A.    Arch.  f.  Kindk.     1898.     25:66. 

156.  Auche  et  Chambrelente.     Press  med.     Mar.  22,  1898.     Also 

Arch,  de  med.  exp.  et  d'anat.  path.     1899.     11 1521. 

157.  Veszpremi,  D.     Centrbl.  f.  Path.  Anat.     1904.     15:483. 

158.  Dufour,  H.,  et  Thiers,  J.    Bui.  Soc.  de  Ped.  de  Paris.     1913. 

16:274. 

159.  Brindeau.     Arch.  ped.    July,  1899. 

160.  Stockel.     Beitr.    z.    Klin.    d.    Tuberk.      1904.      1  :i29.     Also 

Munch.  Med.  Woch.     1908.    No.  10:535. 

161.  Zarfl,  M.    Ztschr.  f.  Kindk.     1913.    8:  No.  5. 

162.  Bugge,  J.     Ziegler's  Beitr.     1896.     19:433. 

163.  Moller,  W.     Arch.  mens,  d'obst.  et  de  gyn.     1914.    3 :  No.  7. 

164.  Gulee  and  Harms.     Tr.   Chicago  Ped.   Soc.     Jan.  20,   1914. 

Also  Am.  Jr.  Dis.  Childn.     1914.    9:  No.  4. 

165.  Delmas.     L'Obstetrique.     May,  1910. 

166.  Bourges.    Jhrb.  f.  kindk.    47  :  No.  1. 

167.  Demme,  R.     Ber.  u.  d.  Thatigk.  d.  Jenners.  Kindsp.  in  Bern. 

1868.    No.  6.    1875.    No.  13.    1880.    No.  17.    1886.    No.  24. 

168.  Merkel.     Cited  by   Ohlendorff,   Ztschr.    f.   Klin.   Med.      1884. 

v.  8 :  No.  6. 

169.  Baumgarten,  P.     Arb.  a.  d.  Path.  Anat.  Inst.  z.  Tub.     1 :322. 

Also  Sam.  Klin.  Vortr.    No.  218. 

170.  Berti.     Bol.  delle  sc.  med.    Bologna,  1882. 

171.  Demme,  R.     Verhl.  d.  Vrsml.  Deutsch.  Naturf.  u.  Arzte.     Frei- 

burg, 1884.    v.  j. 

172.  Money,  P.     Brit.  Med.  Jr.     1885.     1  :i247. 

173.  Gueyrat,  L.     Contribution  a  l'etude  de  la  tuberculose  du  premier 

age.     Paris,  1886.     p.  179. 

174.  Flesch.    Jhrb.  f.  Kindk.     1886.     No.  25.    Also  Pest.  Med-chir. 

Presse.     22 :830. 

175.  Frobelius.    Jhrb.  f.  Kindk.     1886.    No.  24:47. 

176.  Houtinel.     These  de  Paris.     1886. 


CONGENITAL  AND  PLACENTAL  TUBERCULOSIS  93 

177.  Lannelongue,  O.  M.     In  Verneuil's  Etudes  sur  la  tuberculose. 

1887.     1. 

178.  Huguenin.     Cited  by  Lebkuchner  in  Gaz.  des  hop.     1888.     61 : 

785- 

179.  Bosselut,  F.    Contribution  a  l'etude  de  la  meningite  tuberculeuse 

chez  les  jeunes  en f ants  agea  de  moins  de  deux  ans.     Paris, 
1888. 

180.  Rindfleisch.    Ber.  d.  63ten.  Natf.  Vrsml.    Bremen,  1890. 

181.  Sarwey.    Arch.  f.  Gyn.    43 1162. 

182.  Wassermann.    Ztschr.  f.  Hyg.  u.  Inf.    17:343. 

183.  Straus,  I.    Rev.  gen.  de  l'antiseps.  med.  et  chir.    8:97. 

184.  Kissel.     Arch.  f.  Kindk.     25 :6y. 

185.  Holt,  L.  E.    Med.  News.    69:656. 

186.  Henoch,  E.     Vorlesung  iiber  Kinderkrankheiten.     Berlin,  1897. 

187.  Bonnet,  M.  L.    Lyon  med.    87  :224. 

188.  Johnson,  H.  M.    Phil.  Med.  Jr.    3:231. 

189.  Lebkuchner,  F.     Arb.  a.  d.  Path-Anat.  Inst.  z.  Tub.     1899,  3- 

190.  Friedmann,  F.  F.    Deutsch.  Med.  Woch.    1900.    26:381. 

191.  Lyle,  B.  F.    Phil.  Med.  Jr.     1900.    6:219. 

192.  Lehmann,  F.     Deutsch.    Med.  Woch.     19:200. 

193.  Harbitz,  F.    Munch.  Med.  Woch.    April  6,  1913. 

194.  Warthin,  A.  S.    Jr.  Am.  Med.  A.     1913.    61 11951. 

195.  Carl.    Ziegler's  Beitr.     1907.  v.  41. 

196.  Schmorl  und  Kockel.    Ziegler's  Beitr.    1894.    16:313. 

197.  Jung.     Monschr.  f.  Gebh.  u.  Gyn.     23:191. 

198.  Warthin,  A.  S.    Med.  News.    69:319. 

199.  Auche  und  Chambrelente.     Munch.  Med.  Woch.     45:616. 

200.  Wollstein,  M.    Arch.  ped.    22:321. 

201.  Walther,  C.     Beitr.  f.  Path.  Anat.  v.  41.     No.  3. 

202.  Leuenberger,  L.    Beitr.  z.  Gebh.  u.  Gyn.     15:456. 

203.  Landouzy,  L.,  et  Martin,  H.    Rev.  de  med.     3  :ioi4. 

204.  Huguenin,  B.     Centrbl.  f .  Bakt.  Par.  Inf.    48  ^94. 

205.  Charron  et  Karth.     Rev.  de  med.     5  :659. 

206.  Landouzy,  L.    Rev.  de  med.     11:431. 

207.  Aviragnet,  E.  C.    Gaz.  hebd.  de  med.    29  409. 

208.  Thiercelin,  E.,  et  Londe,  P.    Med.  mod.    4  ^98,  also  Gaz.  des 

hop.  66:189. 

209.  Londe,  P.    Res.  de  la  tuberc.     1893,  p.  125. 

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211.  Kynoch,  J.  A.     Scot.  Med.  Surg.  Jr.    20:1018. 

212.  Armanni.    Tr.  10th  Int.  Med.  Con.,  1890. 


94  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

213.  Bolognesi,  A.    These  de  Paris,  1895. 

214.  Henke.    Arb.  a.  d.  Path-Anat.  Inst.  z.  Tub.     1896.     No.  2. 

215.  Kurbitz.    Munch.  Med.  Woch.    1908.  p.  535. 

216.  Rielander,  A.,  und  Mayers,  K.     Arch.  f.  Gyn.     87:131. 


CHAPTER  V 

INFECTION  IN  GENITAL  TUBERCULOSIS 

Routes  of  infection  in  genital  tuberculosis — Primary  genital  tuberculosis — Modes  of 
infection — History  of  cases — Relative  infrequency  in  women — Analysis  of  litera- 
ture— Summary  of  experiments — Clinical  proof — Secondary  genital  tuberculosis — 
Latency  of  the  disease — Determination  of  source  of  infection — Difference  of 
opinion  regarding  frequency  of  primary  and  secondary  infections  of  female 
genital  tract — Study  of  cases — Summary — Predisposing  causes — Frequency — His- 
tologic examination. 

ROUTES  OF  INFECTION 

Primary  Genital  Tuberculosis. — Tubercle  bacilli  may  gain  access 
to  the  genital  tract  in  a  number  of  ways.  A  phthisical  patient  may  con- 
taminate a  douche  nozzle  or  other  article  with  sputum  or  other  infected 
material,  which  may  be  brought  in  contact  with  the  genitalia,  and  thus 
produce  what  is  to  all  intents  and  purposes  a  primary  genital  tuberculosis. 
This  auto-infection,  endogenous,  or  primary-secondary  infection,  as  it  is 
termed  by  Pozzi,1  is,  however,  more  theoretical  than  practical,  for  it  is 
impossible  to  positively  exclude  the  hematogenic  or  lymphogenic  route 
under  such  circumstances,  unless  an  autopsy  is  performed.  Even  then  it 
is  often  difficult.  Under  the  latter  conditions  more  or  less  well  developed 
areas  of  tuberculosis  are  often  found  along  the  route  of  the  infection, 
if  the  case  has  been  one  of  hematogenic  or  lymphogenic  type.  Sachs  2 
has  very  properly  pointed  out  that  the  term  "primary  genital  infection" 
should  be  reserved  for  those  cases  in  which  no  other  focus  of  tubercu- 
losis exists  within  the  patient's  body.  The  difficulty  in  positively  deter- 
,  mining  this  point  has  already  been  referred  to,  and  makes  this  classifi- 
cation faulty,  as  in  many  cases  this  cannot  be  positively  ascertained.  The 
fact,  however,  that  primary  genital  infection  may  occur  shows  that  the 
primary-secondary  infection  is  possible  and  should  lead  to  prophylactic 
measures  being  instigated  in  tuberculous  women. 

On  account  of  the  frequency  of  tuberculosis,  especially  pulmonary 
phthisis,  its  well  known  latency,  and  the  fact  that  small  lesions  not  in- 
frequently heal,  certain  writers  have  doubted  the  existence  of  primary 
genital  infection.  Primary  genital  tuberculosis  by  direct  infection  from 
without  is  extremely  rare,  and  many  of  the  examples  of  this  condition 

95 


96  GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

found  in  literature  are  not  above  suspicion.  Aman  3  rightly  holds  that 
marriage  with  a  tuberculous  man  offers  more  chances  of  infection  through 
the  respiratory  or  alimentary  tract  than  through  the  genital  apparatus. 
In  proof  of  this  assertion,  he  points  to  the  fact  that  the  tubercle  bacillus 
is  non-motile  and  can,  therefore,  only  follow  the  secretion  current  which 
in  the  uterus  and  vagina  is  outwards.  He  states  that  in  rare  instances 
primary  genital  tuberculosis  may  occur  in  young  children  by  direct  infec- 
tion. Even  were  we  to  admit  all  of  Aman's  conclusions,  many  of  which 
are  not  borne  out  by  our  knowledge  of  the  action  of  tubercle  bacilli  in 
other  parts  of  the  body,  we  must  remember  that  it  is  at  least  possible  for 
the  organism  to  gain  access  to  the  endometrial  cavity  by  adhering  to 
spermatozoa,  which  can  readily  make  headway  against  the  outflowing 
secretions  of  the  genital  tract.  Veit,4  after  an  instructive  dissertation  on 
tuberculosis  of  the  female  genital  tract,  summarizes  his  remarks  as  fol- 
lows :  ( i )  Tuberculosis  of  the  female  genital  tract  is  more  frequent 
than  is  generally  thought.  (2)  There  is  a  primary  form,  but  the  sec- 
ondary is  the  more  frequent.  (3)  The  infection  is  usually  a  descending 
rather  than  an  ascending  one.  (4)  Recovery  may  occasionally  occur 
spontaneously.  (5)  The  best  treatment  of  the  primary  form  is  extir- 
pation. (6)  In  the  secondary  forms  the  treatment  should  be  directed 
toward  improvement  of  the  general  health  and  operative  intervention  in 
selected  cases. 

Gutierre  5  at  the  same  meeting  gave  an  account  of  some  original  work, 
the  results  of  which  strongly  favored  the  theory  of  primary  infection  in 
certain  cases.  Von  Rosthorn6  emphasizes  the  rarity  of  the  primary  form 
and  the  difficulty  of  positively  excluding  other  tuberculous  lesions.  A 
similar  statement  is  made  by  Wiener.7  Blau  8  examined  36  cases  from 
Chrobak's  clinic  and  failed  to  find  a  single  one  which  he  would  accept  as 
primary.  That  primary  genital  tuberculosis  occurs  is  now  well  recognized 
and  is  practically  proven  by  the  many  cases  which  have  been  recorded, 
in  which  no  other  lesions,  except  those  observed  in  the  genital  system, 
have  been  found,  even  when  careful  autopsies  were  performed.  Assur- 
ance of  it  is  strengthened  by  the  fact  that  frequently,  when  the  genital 
focus  has  been  removed  by  operation,  perfect  health  has  been  maintained 
for  long  periods. 

That  wound  infection  by  the  tubercle  bacillus  is  not  particularly  in- 
frequent is  well  known.  Holt9  has  collected  16  cases  of  tuberculosis  ac- 
quired through  ritual  circumcision,  infection  by  tatooing  has  been  re- 
corded, and  numerous  other  instances  of  wound  infection  are  on  record. 
When  tuberculous  lesions  are  present  in  the  genitalia  of  a  man,  the 
micro-organisms  must  not  infrequently  be  introduced  into  the  vagina 


INFECTION  IN  GENITAL  TUBERCULOSIS  97 

and  on  the  external  genitalia  of  the  wife.  It  seems  also  to  be  proven 
that  in  rare  instances  tubercle  bacilli  may  be  found  in  the  spermatic 
fluid  of  tuberculous  men  whose  genital  tract  is  healthy.  Doubtless  the 
reason  that  primary  genital  tuberculosis  in  women  whose  husbands  have 
tubercle  bacilli  in  their  spermatic  fluid  is  so  rare,  lies  largely  in  the  pro- 
tective properties  of  the  vagina,  which  is  lined  by  multiple  layers  of 
squamous  epithelium  that  offers  an  excellent  protective  barrier  against 
infection  of  any  kind.  The  bactericidal  properties  of  the  vaginal  secre- 
tion have  also  been  amply  proven  by  Dubendorfer,10  Pankow,11  Menge,12 
and  many  others.  Numerous  animal  experiments  have  been  carried  out, 
most  of  which  tend  to  show  that  virulent  tubercle  bacilli  may  be  deposited 
on  the  normal  vagina  without  producing  infection,  but  that,  if  the  vaginal 
mucosa  be  traumatized  or  an  inflammation  be  present,  a  route  of  ingress 
is  produced  and  infection  may  result.  In  subsequent  pages  these  experi- 
ments will  be  reviewed  more  fully.  It  is  only  in  extremely  rare  instances, 
if  ever,  that  tubercle  bacilli  deposited  in  the  normal  vagina  produce 
lesions. 

Much  has  been  written  upon  the  question  of  coitus  as  a  mode  of 
primary  genital  infection.  Infection  by  coitus  may  be  taken  as  a  type 
representing  all  forms  of  direct  genital  infection.  Cohnheim  13  was  the 
first  to  suggest  this  form  of  infection.  Three  years  later  Verneuil 14 
stated  that  tuberculous  men  with  sound  genital  organs  might  transmit  the 
infection.  As  is  well  known,  genital  or  urinary  tuberculosis  in  men  is 
by  no  means  infrequent,  and  numerous  cases  have  been  recorded  in  which 
the  husband  is  supposed  to  have  infected  his  wife  in  this  way. 

Veit  4  and  Martin  15  state  that  tuberculosis  of  the  male  genital  tract 
occurs  in  three  per  cent  of  all  cases.  The  positive  proof  that  infection 
has  been  transmitted  by  coitus  is  extremely  difficult  to  obtain.  Tubercle 
bacilli  are  frequently  found  in  the  seminal  discharge  of  tuberculous  men. 
When  a  tuberculous  epididymitis  or  orchitis  is  present,  the  seminal  dis- 
charges almost  invariably  contain  tubercle  bacilli,  while  in  some  cases, 
notably  those  of  d'Aubeau,16  the  discovery  of  the  bacilli  in  the  semen, 
without  any  lesions  in  the  genitalia,  was  the  first  evidence  of  phthisis. 
Jani 17  and  others  have  recorded  finding  tubercle  bacilli  in  the  testes  of 
phthisical  men  in  whom  no  demonstrable  genital  lesions  were  present. 

On  theoretic  grounds,  tubercle  bacilli,  circulating  in  the  blood,  should 
not  gain  access  to  the  testicular  or  prostatic  fluids,  but  should  be  en- 
meshed in  the  fine  capillaries  leading  to  the  glandular  structures  of  these 
organs;  but  Grawitz  18  has  demonstrated  that  corpuscles  and  mold  germs 
(which  are  larger  than  tubercle  bacilli)  may,  under  certain  circumstances, 
reach  the  testicular  secretion  from  the  blood  stream.     Murphy  19  points 


98    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

out  that  it  is  sometimes  extremely  difficult  to  diagnose  tuberculosis  of 
the  seminal  vesicle,  and  suggests  that  under  conditions  such  as  have 
just  been  mentioned,  tuberculous  genital  lesions  may  have  been  over- 
looked. Rohlff  20  and  Westmayer 21  have  demonstrated  that  tubercle 
bacilli  are  rarely  present  in  the  spermatic  fluid  of  tuberculous  men,  unless 
genital  lesions  are  present.  The  former  inoculated  goats  and  rabbits 
with  the  spermatic  fluid  obtained  from  ten  men  who  died  of  phthisis, 
with  negative  results.  The  latter  injected  ground  up  particles  of  the 
testicles  and  ovaries,  of  patients  who  had  died  of  tuberculosis,  into  the 
peritoneal  cavity  of  rabbits,  with  similar  results  in  14  observations. 
Dobrolonski  22  tested  the  contents  of  the  seminal  vesicles  of  25  men 
who  died  of  phthisis,  by  means  of  smears  and  inoculation.  Twenty-four 
were  negative  and  the  one  positive  result  was  obtained  from  a  subject 
in  whom  a  tuberculous  epididymitis  was  present.  Walther  23  examined 
161  sections  from  the  testes,  48  from  the  epididymis,  63  from  the  pros- 
tate, from  the  bodies  of  twelve  phthisical  men,  without  finding  a  single 
tubercle  bacillus. 

Murphy  19  reports  a  case  of  tuberculous  salpingitis,  in  which  the  in- 
fection is  supposed  to  have  been  transmitted  by  coitus.  He  remarks, 
however,  upon  the  infrequency  of  this  mode  of  infection.  Derville  24 
reports  the  histories  of  8  cases,  all  of  which  are  suggestive  of  this  variety 
of  infection.     Fernet  and  Derville  25  and  Sheills  26  report  similar  cases. 

The  relative  infrequency  of  genital  tuberculosis,  in  women  whose  hus- 
bands are  known  to  be  the  incumbents  of  tuberculous  genital  or  urinary 
lesions,  seems  to  be  a  proof  that  the  simple  deposition  of  virulent  tubercle 
bacilli  in  the  vagina  is  not  productive  of  tuberculosis  in  the  female  gen- 
erative organs  under  ordinary  circumstances.  Many  experiments  have 
been  performed  with  the  view  of  determining  this  point,  and  more  or 
less  contradictory  results  have  been  obtained.  After  having  studied  the 
somewhat  voluminous  literature  upon  this  subject  and  carefully  analyzed 
the  results  obtained,  no  one  can  fail  to  be  impressed  with  the  fact  that 
virulent  tubercle  bacilli,  when  deposited  within  the  normal  vagina,  do 
not,  under  ordinary  circumstances,  produce  either  local  or  general  lesions, 
but  that  some  trauma,  loss  in  continuity  of  the  vaginal  lining,  or  special 
susceptibility  of  the  new  host,  is  necessary  before  the  tubercle  bacilli 
can  produce  pathologic  changes.  The  vagina  and  portio  vaginalis  are 
invested  by  multiple  layers  of  stratified  squamous  epithelium  and  differ 
but  little  in  their  histologic  structure  from  the  skin.  Indeed,  histological 
investigation  tends  to  prove  that  the  vaginal  lining  is  a  modified  skin 
and  is  in  no  sense  a  mucous  membrane.  In  the  course  of  ordinary,  mod- 
ern life,  tubercle  bacilli  are  probably  frequently  brought  in  contact  with 


INFECTION  IN  GENITAL  TUBERCULOSIS  99 

the  exposed  surfaces  of  the  body,  and  in  phthisical  individuals,  unless 
the  strictest  prophylaxis  is  enforced,  the  patient's  skin  must  very  often 
be  contaminated;  yet  tuberculosis  of  the  skin,  resulting-  from  this  form 
of  infection,  is  extremely  infrequent.  The  outward  flow  of  the  vaginal 
and  uterine  secretions,  the  general,  downward  direction  of  the  genital 
canal  which  favors  drainage,  and  the  more  or  less  occlusive  cervical 
secretion  in  the  canal  with  the  bactericidal  properties  of  the  vaginal  se- 
cretion, all  doubtless  play  a  part  in  preventing  the  ascent  of  the  non- 
motile  tubercle  bacilli  which  must  occasionally  be  deposited  in  the  vagina 
of  women,  the  wives  of  tuberculous  men.  The  relative  frequency  with 
which  genital  tuberculosis  develops  after  abortion  or  labor,  and  its  in- 
frequency  in  wives,  the  husbands  of  whom  are  known  to  have  genital  or 
urinary  lesions  and  who*  must  frequently  be  exposed  in  this  manner  to 
the  action  of  the  tubercle  bacilli,  is  further  clinical  proof  of  this  as- 
sumption. 

Bull  27  relates  an  interesting  case  bearing  upon  this  point.  A  man 
contracted  tuberculosis  in  his  youth,  later  married,  and  at  the  end  of 
one  year  a  healthy  child  was  born.  Two  years  later  it  was  necessary  to 
remove  the  right  testicle  and  epididymis  for  tuberculosis.  At  this  time 
the  left  testicle  was  also  diseased,  but  was  spared.  One  year  later  the 
prostate  became  involved.  No  further  operative  treatment  was  insti- 
gated. Examination  of  the  spermatic  fluid  at  this  time  showed  the  ab- 
sence of  the  characteristic  odor  and  of  the  Florence  reaction;  an  injec- 
tion into  guinea  pigs  was  positive  for  tuberculosis.  During  this  period 
of  advancing  genital  infection,  the  wife  had  borne  two  children.  These 
children  showed  no  evidence  of  tuberculosis  and  were  negative  with  the 
Von  Pirquet  test.    The  wife  presented  no  symptoms  of  genital  infection. 

Undoubtedly  infection  by  coitus  may  occur  in  a  number  of  ways. 
As  already  mentioned,  the  spermatic  fluid  may  contain  virulent  tubercle 
bacilli,  either  as  a  result  of  an  internal  genital  lesion,  or  from  the  urinary 
tract.  The  penis  itself  may  be  the  seat  of  a  tuberculous  ulcer,  or  the 
organism  may  be  upon  the  external  surface  of  a  normal  male  organ. 

Numerous  animal  experiments  have  from  time  to  time  been  per- 
formed in  an  effort  to  determine  the  effects  produced  by  the  deposition 
of  tubercle  bacilli  into  the  vagina.  A  summary  of  these  experiments 
shows  that  ( 1 )  Tubercle  bacilli  when  deposited  in  the  normal  adult  vagina 
rarely  if  ever  produce  lesions.  (2)  When,  however,  the  vaginal  lining 
has  been  traumatized  and  there  is  loss  of  continuity  of  the  lining  mem- 
brane, infection  may  occasionally  occur.  (3)  Similar  results  are  likely 
to  take  place,  if  the  vaginal  lining  has  been  inflamed,  either  by  chemical 
or  bacteriologic  means.     (4)   Pregnancy  and  the  puerperium  favor  in- 


ioo        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

fection,  especially  the  latter.  (5)  When  infection  occurs  it  may  be  local, 
distant  or  a  general  tuberculosis  may  be  set  up.  The  amount  or  character 
of  the  trauma  or  irritation  does  not  seem  to  be  a  guide  in  this  respect. 

(6)  Tuberculosis  may  result  from  the  spread  of  the  mumicroorganism 
in  the  vagina  to  distant  parts  of  the  body  without  producing  local  lesions. 

(7)  The  route  of  the  infection  appears  to  be  through  the  lymphatics,  the 
pelvic  glands  usually  being  involved.  (8)  Local  infection  occurs  in  only 
the  minority  of  cases.  (9)  Young  animals  seem  to  be  slightly  more  sus- 
ceptible than  old.  (10)  When  tubercle  bacilli  are  deposited  within  the 
uterus,  the  percentage  of  infections  is  increased.  For  further  details  of 
research  on  this  subject,  the  reader  is  referred  to  the  works  of  Cornet, 
Flugge,  Dobrolonski,  Cornil,  Oncarani,  Basso,  Jung  and  Bennecke,  Blau, 
Varaldo,  Andrews,  Sugimura,  Hartmann,  Williams,  Gorovitz  and  Popov. 

In  view  of  the  above  clinical  and  experimental  evidence  it  appears  to 
be  an  established  fact  that  in  rare  instances  tuberculosis  may  be  spread 
by  coitus.  Precautions  are,  therefore,  indicated,  particularly  in  those 
cases  in  which  there  is  a  tuberculous  lesion  in  the  genito-urinary  tract. 

As  has  already  been  stated,  tubercle  bacilli  may  be  deposited  in  the 
genital  tract  in  a  number  of  ways  :  coitus,  septic  instrumentation,  infected 
fingers,  douche  nozzles,  dressings,  etc.  All  these  should  be  guarded 
against.  In  not  a  few  cases,  lesions  of  the  lower  genital  tract  have  been 
attributed  to  tubercle  bacilli  bearing  endometrial  or  tubal  secretions,  A 
number  of  cases  have  been  recorded  in  which  the  genital  lesions  were 
plainly  the  result  of  infected  discharges  from  tuberculous  intestines,  the 
access  of  the  tubercle  bacilli  being  gained  to  the  genital  tract  through  a 
rectovaginal,  or  other  form  of  fistula.  The  tubercle  bacilli  may  also 
gain  access  to  the  genital  tract  through  contamination  of  the  latter  by 
diarrheal  discharges,  the  result  of  tuberculous  lesions  in  the  alimentary 
tract.  In  the  same  manner  genital  tuberculosis  may  result  from  tuber- 
culous lesions  in  the  urethra,  kidney,  ureter,  bladder ;  or  the  lower  genital 
tract  may  be  contaminated  by  discharges  originating  from  a  salpingitis 
or  endometritis.  It  will  be  noted  that  a  large  proportion  of  the  above 
mentioned  lesions  produce  conditions  which  result  in  constant  and  pro- 
longed irritation,  and  that  in  many  cases,  as  a  result  of  the  discharges, 
a  local  inflammatory  reaction  results.  This  is  probably  a  factor  in  lessen- 
ing the  resistance  of  the  parts  and  thus  making  them  more  susceptible 
to  the  action  of  the  tubercle  bacilli.  Another  method  of  infection  is  by 
direct  extension.  Thus  the  genital  lesion  may  be  due  to  a  direct  exten- 
sion of  a  tuberculous  focus  in  the  bowel,  bladder,  or  other  adjacent  struc- 
ture, either  by  way  of  a  fistula  or  through  adherent  inflammatory  struc- 
tures without  actual  macroscopic  loss  of  continuity.    The  infection,  espe- 


INFECTION  IN  GENITAL  TUBERCULOSIS  101 

daily  of  the  tubes,  may  and  frequently  does  follow  tuberculous  peritonitis. 
The  question,  under  such  circumstances,  which  is  the  primary  lesion,  is 
sometimes  difficult  to  determine.  Tuberculosis  of  the  adnexa  may  result 
from  a  direct  extension  from  a  peritonitis,  from  a  deposition  by  the  peri- 
toneal currents  of  tubercle  bacilli  in  the  peritoneal  fluids,  or  may  be  purely 
secondary  infection  resulting  from  a  lymphogenous  or  hematogenous 
origin.  These  three  possibilities  are  of  more  theoretic  than  practical 
importance.  The  works  of  Muscatello,28  Clark  and  Norris,29  and 
others  have  amply  proven  that  the  general  direction  of  the  intraperi- 
toneal currents  is  towards  the  diaphragm  and  that  the  chief  absorption 
of  the  peritoneal  fluids  occurs  in  the  neighborhood  of  the  central  tendon 
of  the  latter  structure.  When,  however,  the  openings  of  the  lymphatics 
of  the  diaphragm  become  blocked  with  debris,  as  in  the  case  of  peritonitis 
or  ascites,  absorption  through  this  structure  is  greatly  diminished,  as  has 
been  shown  by  the  experimental  work  of  Waterhouse 30  and  others. 
Pinner 31  demonstrated  that  when  powdered  cinnabar  was  introduced 
into  the  peritoneal  cavity  of  rabbits,  a  small  proportion  of  it  eventually 
found  its  way  into  the  vagina  through  the  tubes  and  uterus,  and  it  would 
seem  probable,  therefore,  that  in  the  case  of  a  tuberculous  peritonitis, 
tubercle  bacilli  might  in  the  same  way  be  swept  out  through  the  genital 
tract  and  secondarily  produce  a  lesion  in  the  cervix,  vagina  or  external 
genitalia.  Jani  demonstrated  tubercle  bacilli  at  autopsy  in  the  lumen 
of  a  macroscopically  normal  fallopian  tube  in  a  phthisical  patient.  An 
ulceration  of  the  intestine  was  also  present.  In  this  case  the  tubercle 
bacilli  may  possibly  have  been  carried  to  the  tube  by  way  of  the  blood 
stream.  Kaufmann  32  was  one  of  the  first  to  record  the  history  of  a 
case  in  which  tuberculosis  of  the  genital  tract  was  the  result  of  direct 
infection  from  a  tuberculous  intestine  and  genital  fistula.  In  his  case 
there  was  a  fistulous  opening  between  the  small  intestine  and  uterus. 
Kraus 33  has  reported  a  case  of  ovarian  tuberculosis,  which  resulted 
from  a  similar  infection  of  the  vermiform  appendix. 

Secondary  Genital  Tuberculosis. — Under  this  head  should  be 
classified  many  of  the  methods  of  infection  just  described.  For  reasons 
already  stated,  it  is  sometimes  extremely  difficult,  when  two  separate 
foci  of  tuberculosis  are  present  in  a  patient,  to  determine  which  lesion 
has  been  the  primary  one.  The  well  known  latency  of  the  disease,  the 
fact  that  the  primary  lesion  is  not  necessarily  the  most  advanced  and  may 
have  become  of  much  less  clinical  severity  or  may  even  have  progressed 
to  resolution  before  the  secondary  lesion  has  advanced  to  sufficient  mag- 
nitude to  attract  attention,  add  greatly  to  this  difficulty,  and  make  the 
determination  of  the  source  of  primary  infection  almost  impossible  to 


102        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

positively  ascertain,  unless  a  careful  postmortem  can  be  performed,  and 
even  then  is  often  difficult.  The  study  of  tuberculosis  in  parts  of  the 
body  other  than  the  genital  tract  and  the  preponderance  of  this  infection 
in  certain  localities,  such  as  the  lungs,  may,  however,  to  all  intents  and 
purposes,  practically  clear  up  this  difficult  problem.  Many  forms  of  tu- 
berculosis are  at  some  stage  bacteriemias.  When,  therefore,  genital 
lesions  are  present  in  conjunction  with  phthisis,  the  latter  should  be 
considered  the  primary  focus. 

Authorities  differ  widely  in  their  opinions  regarding  the  frequency 
of  primary  and  secondary  infections  of  the  female  genital  tract. 
Frerich  34  states  that,  of  the  genital  tuberculoses  in  women,  6  per  cent 
are  primary;  Mosler  35  places  the  proportion  at  17.3  per  cent;  Spath,36 
at  24.5  per  cent;  Schramm,37  20.9  per  cent;  Merlitti,38  at  18.6  per  cent; 
Berkley,39  10.8  per  cent;  Frerichs,40  at  15.6  per  cent;  and  Horizontow,41 
10  per  cent.  Williams  42  is  of  the  opinion  that  blood  infections  are  more 
frequent  than  generally  supposed.  Villard  43  found  the  lungs  diseased 
in  one  half  of  the  cases  of  genital  tuberculosis. 

For  reasons  already  stated,  the  estimate  of  the  proportion  of  primary 
and  secondary  genital  tuberculosis  is  necessarily  extremely  difficult  and 
cannot  be  accurately  determined.  From  a  study  of  the  cases  which  have 
been  treated  in  the  gynecological  department  of  the  University  of  Penn- 
sylvania, it  would  seem  that  secondary  infections  are  by  far  the  most  fre- 
quent, probably  not  more  than  5  or  at  most  10  per  cent  being  primary. 
Obviously  the  question  as  to  whether  a  given  case  is  a  primary  or  sec- 
ondary infection  is  of  great  importance  in  governing  the  prognosis  and 
treatment. 

To  summarize — Genital  tuberculosis  may  arise  in  one  of  four 
ways: 

1.  By  direct  infection  from  without.  This  is  a  rare  form,  but  its 
existence  has  been  definitely  proven  both  clinically  and  experimentally. 
The  infective  organism  may  come  from  the  patient's  own  mouth  or  other 
lesion  by  way  of  the  hands,  etc.,  or  may  originate  in  another  host  and 
be  conveyed  to  the  woman's  genital  tract  by  coitus,  septic  examina- 
tions, etc. 

2.  Infection  of  the  genitalia  may  be  secondary  by  way  of  the  blood 
stream ;  the  primary  focus  may  be  distant  or  near  at  hand,  the  lungs  being 
the  most  frequent  site  for  the  primary  infection.  This  is  a  frequent  form 
of  genital  infection. 

3.  Infection  may  result  from  a  direct  extension  from  a  nearby  focus, 
such  as  the  peritoneum,  intestine,  bladder,  etc.  This  also  is  a  frequent 
method  of  infection. 


INFECTION  IN  GENITAL  TUBERCULOSIS  103 

4.  Infection  may  result  from  a  lymphatic  infection,  usually  from 
a  comparatively  nearby  focus. 

Predisposing  Causes  of  Genital  Tuberculosis. — As  has  been 
stated,  genital  tuberculosis  is  more  frequent  in  the  female  than  in  the 
male.  This  can  probably  be  largely  accounted  for  on  an  anatomical 
basis.  In  cases  of  tuberculous  peritonitis,  the  tubes  are  naturally  exposed 
to  infection.  The  lower  genital  tract  in  women  is  also  more  subject  to 
invasion  by  tubercle  bacilli  bearing  discharges  from  the  alimentary  tract 
and  from  external  infection  in  general,  than  are  the  corresponding  organs 
in  the  male.  Von  Franque  44  and  Murphy  are  of  the  opinion  that  tuber- 
culous salpingitis  usually  results  from  an  infection  via  the  peritoneum. 
In  many  of  our  cases  the  reverse  has  been  true.  The  congestion  incident 
to  menstruation  and  pregnancy  and  the  trauma  of  the  latter  are  also 
predisposing  factors.  Gonorrhea  seems  in  many  cases  to  prepare  the  soil 
for  the  invasion  of  the  tubercle  bacilli,  and  the  same  may  be  said  of  any 
inflammation,  especially  chronic  ones.  Loss  of  continuity  of  the  surface 
epithelium  appears  in  many  cases  to  offer  an  entry  way  for  the  tubercle 
bacilli.  Schuchardt,45  Saulmann,46  and  others  have  directed  attention 
to  the  frequency  with  which  tuberculosis  follows  or  occurs  concomitantly 
with  venereal  diseases.  The  age  is  undoubtedly  a  predisposing  factor, 
but  this  varies  with  the  character  of  the  lesion  and  will  be  considered 
under  the  description  of  the  various  organs.  Hegar,  Merlitti,38  de  Rou- 
ville,47  Schiffmann  48  and  others  are  of  the  opinion  that  hypoplasia  of  the 
genital  organs  is  a  strong  predisposing  factor  to  tuberculosis.  A  study 
of  our  series  of  cases  has  not  borne  out  this  opinion. 

Frequency  of  Genital  Tuberculosis. — Genital  tuberculosis  is  more 
frequent  in  women  than  in  men.  According  to  Amann,3  20  per  cent  of 
tuberculous  lesions  involve  the  genital  tract  in  females  and  3  per  cent  in 
males.  In  many  cases  tuberculosis  of  the  genital  tract  can  only  be  diag- 
nosed by  the  microscope  or  by  culture  or  inoculation,  and  the  proportion 
of  cases  in  which  the  macroscopic  lesions  are  sufficiently  characteristic 
to  lead  to  a  positive  diagnosis  is  by  no  means  large.  Williams  38  states 
that,  in  his  series  of  cases  of  tuberculosis  of  the  genitalia,  75  per  cent 
were  of  the  "unsuspected  variety"  and  were  only  diagnosed  when  the 
tissue  was  examined  histologically.  This  difficulty  in  making  macro- 
scopic diagnoses  of  genital  tuberculosis  is  probably  largely  accountable 
for  the  divergent  results  reported  by  various  pathologists  and  surgeons. 
Thus  Courts  49  found  genital  tuberculous  lesions  in  1  per  cent  of  women 
dying  of  tuberculosis;  Louis,50  in  2.5  per  cent,  and  Cornil,51  in  2  per 
cent;  Kiwisch,52  in  2.5  per  cent,  and  Mosler,35  in  2.5  per  cent; 
Schramm,37  in  4.1  per  cent;  Nimias  and  Christoforis,53  in  8.3  per  cent. 


104        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Owing  to  the  increased  knowledge  of  the  pathology  produced  in  the 
genital  tract  by  the  tubercle  bacilli,  more  recent  references  place  the  pro- 
portion of  genital  infection  much  higher.     In  1901  Merlitti  34  placed  the 
proportion  at  12.6  per  cent,  which  is  the  figure  given  by  Foster.54    Pure- 
foy  55  places  the  proportion  at  7  per  cent.     Martin  15  stated  that  genital 
tuberculosis  was  present  in  4  per  cent  of  females  who  died  of  tuberculo- 
sis before  puberty,  in  12  per  cent  of  those  dying  during  the  child  bearing 
period,  and  in  22  per  cent  of  those  dying  in  later  life.     Berkley,35  in 
statistics  including  the  years  between  1880  and  1902,  found  in  798  necrop- 
sies, performed  in  females  who  died  of  tuberculosis,  the  genital  organs 
affected  in  62,  or  y.j  per  cent.     Simonds  56  gives  the  results  of  6,000 
portmortem  examinations,  which  lead  him  to  the  following  conclusions : 
Tuberculosis  of  the  female  genital  tract  is  found  in  1.5  per  cent  of  all 
cases.     It  is  most  frequent  between  the  ages  of  20  and  30  years.     In  87 
per  cent  the  tubes  are  affected,  and  in  76  per  cent,  the  uterus.     Meyer- 
Riigg  57  states  that  in  2  per  'cent  of  all  female  corpses  there  is  found  to 
be  tuberculosis  of  the  genital  organs.     Taking  into  account  only  women 
dying  of  tuberculosis,  there  is  genital  tuberculosis  in  10  per  cent.     The 
value  of  many  of  the  statistics  regarding  the  frequency  of  genital  tuber- 
culosis is  somewhat  nullified  by  the  fact  that  the  authors  fail  to  state 
whether  routine  histologic  examinations  have  been  made,  or  whether  the 
results  refer  only  to  those  cases  which  have  presented  macroscopic  lesions. 
Probably  the  latter  was  the  case  in  many  of  the  statistics.     Furthermore, 
information  regarding  the  location  of  the  lesion  in  the  genital  tract  is 
not  infrequently  lacking.     The  organs  of  generation  are  involved  in  the 
following  order  of  frequency :   tubes,  uterus,  ovaries,  vagina  and  vulva. 
This  ratio  holds  good,  whether  the  infection  be  primary  or  secondary. 
Berkley  35  presents  the  following  statistics.     His  results  are  from  post- 
mortem subjects.     It  is  not  stated  whether  routine  histologic  examina- 
tion had  been  performed  :    Fallopian  tubes,  30 ;  fallopian  tubes  and  body 
of  uterus,  8;  fallopian  tubes,  body  of  uterus,  and  ovaries,  5;  fallopian 
tubes  and  ovaries,  4 ;  ovaries,  4 ;  cervix,  3 ;  corpus  uteri,  3 ;  vagina,  2 ; 
fallopian  tubes  and  vagina,  1 ;  fallopian  tubes,  body  of  uterus,  and  cervix, 
1 ;  fallopian  tubes,  body  of  uterus,  ovaries  and  vagina,   1.     Thus,  the 
tubes  were  affected  in  80.6  per  cent ;  body  of  uterus,  29  per  cent ;  ovaries, 
28.5  per  cent;  cervix,  6.4  per  cent;  vagina,  6.4  per  cent;  vulva,  o  per  cent. 
Williams,38  whose  material  was  operative  in  origin  and  all  of  which  was 
submitted  to  a  routine  histologic  examination,  is  of  especial  value.     He 
states  that  8  per  cent  of  all  adnexitis  cases  are  of  tuberculous  origin.     In 
nearly  all  cases  the  tubes  were  involved ;  the  uterus,  in  60  to  75  per  cent ; 
and  the  ovaries,  in  40  to  45  per  cent  of  cases.    Cummins,58  in  a  series  of 


INFECTION  IN  GENITAL  TUBERCULOSIS  105 

cases  of  pelvic  inflammatory  disease,  found  10.5  per  cent  to  be  of  tuber- 
culous origin.  Hannes  59  places  the  proportion  at  4.5  per  cent.  Mar- 
tin,15 in  the  routine  histologic  examination  of  lesions  from  the  gyne- 
cological clinic  at  Greifswald,  found  24  tuberculous  specimens  among 
1,600  specimens.  Edebohls,'00  in  157  abdominal  sections,  found  4  per  cent 
were  performed  for  tuberculosis.  Horizontow61  places  the  order  of  in- 
volvement of  the  genital  organs  as  follows:  Tubes,  87  per  cent;  uterus, 
47  per  cent ;  ovaries,  1 5  per  cent ;  the  cervix  secondarily  involved  with  the 
body  of  the  uterus,  14  per  cent;  cervix  alone,  2  per  cent;  vagina  or  ex- 
ternal genitalia,  6  per  cent.  Basing  his  opinion  upon  his  own  and  other 
statistics  gathered  from  postmortems  performed  upon  patients  dying  of 
tuberculosis  in  which  involvement  was  proved,  he  states  that  pulmonary 
lesions  were  present  in  89  per  cent;  peritoneal  lesions,  64  per  cent;  intes- 
tinal in  56  per  cent;  and  lesions  of  the  urinary  tract  in  42  per  cent.  In 
the  laboratory  of  gynecological  pathology  at  the  University  of  Pennsyl- 
vania, where  all  specimens  are  subjected  to  a  routine  histologic  examina- 
tion, it  has  been  found  that  7  per  cent  of  all  the  inflammatory  fallopian 
tubes  are  tuberculous.  Among  6,557  gynecological  specimens  examined 
in  our  laboratory,  there  was  no  case  of  tuberculosis  of  the  external 
genitalia,  there  was  1  case  of  tuberculosis  of  the  vagina,  1  case  of  tuber- 
culosis of  the  cervix  (219  specimens  of  carcinoma  or  other  malignant 
neoplasms  of  the  cervix,  showing  the  relative  frequency  of  tuberculosis 
and  malignant  tumors  of  the  cervix,  a  condition  for  which  tuberculosis 
is  often  clinically  mistaken;  this  also  emphasizes  the  importance  of  def- 
initely excluding  malignancy  before  making  a  diagnosis  of  tuberculosis 
of  the  region)  ;  13  cases  of  tuberculous  endometritis  (all  associated  with 
tuberculous  salpingitis),  4  cases  of  oophoritis,  2  cases  of  tuberculosis  in- 
fecting the  wall  of  ovarian  neoplasms,  7  cases  of  tuberculous  peri- 
oophoritis, 1  case  of  tuberculosis  of  the  breast  (among  166  breast  tu- 
mors, 91  of  which  were  malignant  and  75  benign). 


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106        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

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1897.    661. 

19.  Murphy,  J.  B.  Tuberculosis  of  the  Female  Genitalia  and  Peri- 

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58.  137- 

20.  Rohlff,  E.     Beitrag  zur  Frage  von  der  Erblichkeit  der  Tuber- 

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21.  Westmayer,  E.    Beitrag  zur  Frage  von  der  Vererbung  der  Tuber- 

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22.  Dobrolonski.    Cong.  p.  l'Etude  de  Tuberculose.    Paris,  1889.    265. 

Rev.  de  la  Tuberc.     Paris,  1895,  3,  195.    Fro.  du  Vrach,  1895. 
19-20. 

23.  Walther,  H.     Ziegler's  Beitrag.     1894.     16,  274-284. 

24.  Derville.     These  de  Paris.     1887. 

25.  Fernet  et  Derville.     France  Med.     Paris,  1886,  2,  1673-1685. 

Courrier  Med.    Paris,  1886.    36,488-491. 

26.  Sheills,  E.     Dublin  M.  Sc,  191 7.    43,  84-86. 

27.  Bull,      P.     Deutsche      Med.      Woch.        Leipzig,      1912.         40, 

1882-83. 

28.  Muscatello,  G.    Arch.  f.  Path.  Anat.   Berlin,  1895.    143,  327-359. 

29.  Clark,  J.  G.,  and  Norris,  C.  C.     J.  A.  M.  A.     Chicago,  1901. 

37,  3°0-     J-  A.  M.  A.     Chicago,  1904.     43,  281. 


INFECTION  IN  GENITAL  TUBERCULOSIS  107 

30.  Waterhouse,  H.  J.     Arch.   f.   Path.  Anat.     Berlin,    1890.      119, 

342-361. 

31.  Pinner,  O.     Arch.  f.  Physiol.     Leipzig,  1880.     241-255. 

32.  Kaufmann,  E.     Arch.  f.  Gyn.     Berlin,  1886.     29,  407-408. 

33.  Kraus,  E.    Monatschr.  f.  Geb.  u.  Gyn.    Berlin,  1902.     15,  159-166. 

34.  Frerich.     Quoted  by  Murphy. 

35.  Mosler.     Inaug.  Diss.     Breslau,  1883. 

36.  Spath.    Quoted  by  Murphy. 

37.  Schramm.    Arch.  f.  Gyn.    Berlin,  1882.     19,  416-430. 

38.  Merletti,  C.     Arch,  di  Ostet.  et  Gynec.     Napoli,  1901.     8,  612, 

649,  714. 

39.  Berkley,  C.    Jour.  Obst.  &  Gyn.  Brt.  Emp.    London,  1903.    3,  31. 

40.  Frerichs.     Quoted  by  Berkley. 

41.'  Horizontow.     Zeitschr.  f.  Gyn.     191 1.     52,  1731. 

42.  Williams,  J.  W.    Johns  Hopkins  Hospital  Reports,  1894.     3,  114. 

43.  Villard.     Quoted  by  Cornet. 

44.  von  Franque.     Pathologic  und  Therapie  der  Genital  Tuberculose 

des  Weibes.     Wurzburg,   1913. 

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46.  Saulmann.     Gynak.  Gesellschaft  in  Brussl.     Abstracted  in  Cen- 

tralbl.  f.  gyn.    Apr.,  1892. 

47.  de  Rouville,  M.     Bull.  Soc.  d'Obst.  et  de  Gyn.  de  Paris.     1914.. 

559-563. 

48.  Schiffmann,  J.    Arch.  f.  Gyn.    Berlin,  1914.     103,  1. 

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50.  Louis.    Recherches  sur  la  Phthysie.    Paris,  1843. 

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52.  Kiwisch.     Klin.  Vortrag.     1857.     1-462. 

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103,  326. 

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CHAPTER  VI 

TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA 

Etiology — Possibility  of  hematogenic  or  lymphogenic  infection — Causes — Frequency 
— Combined  statistics  of  many  investigators — Varieties — Forms,  ulcerative  and 
hypertrophic — Symptoms — Number  of  cases  ;  average  age — Relative  inf  requency 
of  direct  infection  in  this  locality — Parturition  as  causative  agent — Trauma 
a  predisposing  factor — History  of  cases — Appearance  of  ulcerative  variety — Hy- 
pertrophic variety — Tabulation  of  parts  involved — Diagnosis — Prognosis—Method 
of  treatment — Primary  variety — Secondary — Doubtful  cases — General  treatment — 
Tuberculous  non-ulcerative  hypertrophy  of  vulva — Histologic  examination — 
Tuberculosis  of  Bartholin's  gland — Tuberculous  ulcers  of  labia  majora  and  minora 
— Histologic  examination — Study  of  cases — Primary  tuberculosis  of  vulva  with 
elephantiasis  of  clitoris — Secondary  hypertrophic  tuberculosis  of  vulva— Reports 
of  cases. 

LESIONS 

Of  all  forms  of  tuberculosis  affecting  the  female  genital  tract,  lesions 
of  the  external  organs  are  the  least  frequent.  This  is  probably  largely 
due  to  the  protective  properties  of  the  squamous  epithelium  with  which 
the  parts  are  covered.  Much  of  the  surface  of  the  external  genitalia  is 
covered  by  skin,  the  outer  layer  of  which  possesses  a  moderately  well 
defined  development  of  horny  squamous  epithelium,  such  as  is  usually 
found  on  the  surface  of  the  integument.  As  the  skin  covering  the 
external  genitalia  approaches  the  lining  membrane  of  the  vagina  this 
outer  horny  layer  gradually  disappears. 

The  tuberculous  lesion  may  be  primary  or  secondary ;  the  latter 
being  by  far  the.  most  common.  Of  fifty-seven  cases,  the  abstracts  of 
which  are  appended,  79  per  cent  occurred  in  conjunction  with  well 
marked  tuberculosis  of  other  parts  of  the  body.  In  66  per  cent  of  these 
cases  the  genital  lesions  were  secondary  to  distant  foci ;  33  per  cent  from 
the  lungs;  5  per  cent  from  the  peritoneum,  and  the  remainder  to  tuber- 
culosis in  other  parts  of  the  body.  In  18  per  cent  of  cases  lesions  in 
the  upper  genital  tract  were  present. 

Winckel  *  was  probably  the  first  to  record  an  authentic  case  of  tuber- 
culosis of  the  external  genitalia.  Cayla's  2  observation  appeared  a  short 
time  later. 

108 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  109 

Etiology. — Lesions  of  the  external  genitalia  may  result  from  a 
direct  inoculation,  or  direct  extension  from  the  vagina  or  adjacent  struc- 
tures, or  from  an  hematogenic  or  lymphogenic  infection.  In  many  of 
the  reported  cases  lesions  of  the  external  genitalia  have  apparently  fol- 
lowed a  direct  implantation,  the  result  of  tubercle  bacilli  bearing  dis- 
charges originating  from  the  lesions  in  the  intestinal,  urinary,  or  upper 
genital  tracts.  In  this  connection,  it  is  interesting  to  observe  that  the  in- 
fection may  be  transmitted  from  the  tubes  to  the  external  genitalia  or 
vagina  without  the  uterus  becoming  involved.  In  these  cases,  the  possi- 
bility of  an  hematogenic  or  lymphogenic  infection  must  be  considered, 
although  a  direct  implantation  would  appear  the  most  likely.  The  relative 
frequency  of  tuberculosis  of  the  uterus  and  the  rarity  of  infection  of  the 
external  genitalia  is  further  proof,  if  such  were  required,  that  the  simple 
deposition  of  tubercle  bacilli  upon  the  normal  vagina" or  external  genitalia 
seldom  results  in  the  production  of  lesions;  for  in  tuberculosis  of  the 
uterus  tubercle  bacilli  are  frequently  discharged  through  the  cervix. 
Tuberculosis  of  the  external  genitalia  may  also  result  from  a  direct 
extension  by  continuity  from  the  vagina  or  adjacent  structures. 

Trauma  appears  to  play  an  important  role  in  the  production  of  sec- 
ondary lesions,  doubtless  by  producing  an  area  of  lessened  resistance. 
In  the  primary  form  it  is  less  frequently  a  factor,  although  a  loss  of 
continuity,  by  opening  up  avenues  for  direct  inoculation,  should  be 
considered.  Preexisting  inflammation  is  also  a  predisposing  cause.  In 
this  manner  the  more  or  less  constant  soaking  of  the  parts  in  toxin  and 
tubercle  bacilli  laden  discharges  probably  first  produces  a  maceration  of 
the  skin,  then  a  vulvitis,  and  finally  an  actual  infection  by  the  tubercle 
bacili.  A  number  of  cases  have  been  recorded  occurring  in  conjunction 
with  syphilis;  gonorrhea  has  also  been  present  in  some  cases.  In  the 
young  vulvovaginitis  has  preceded  the  tuberculosis  in  some  instances. 

Bulkley 3  believes  that,  in  the  primary  form,  infection  frequently 
occurs  either  by  sputum  or  coitus.  Of  the  secondary  variety,  infection 
may  occur  by  the  hematogenous  or  lymphatic  route,  or  by  contiguity 
of  tissue  or  continuity  of  the  surface.  The  actual  route  of  infection 
is  often  difficult  to  determine  in  any  given  case.  As  has  been  stated, 
trauma  or  preexisting  inflammation  apparently  acts  as  a  predisposing 
cause,  especially  in  the  secondary  form  of  the  disease. 

Frequency. — As  has  been  stated,  this  is  the  rarest  form  of  genital 
tuberculosis.  Of  6,657  gynecologic  specimens  in  the  laboratory  of 
Gynecological  Pathology  of  the  University  of  Pennsylvania,  but  two 
examples  of  this  variety  of  infection  have  been  observed.  Williams4 
states  that  at  the  time  of  the  appearance  of  his  monograph,  in  1894, 


no        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

but  three  cases  of  tuberculosis  of  the  external  genitalia  were  found  in 
which  the  correctness  of  the  diagnosis  had  been  verified  by  inoculations. 
The  combined  statistics  of  Geil,5  Mosler,6  Daurios,7  Schiller,8  and 
Martin  9  show  that  among  379  cases  of  genital  tuberculosis  there  was 
no  involvement  of  the  vulva.  The  statistics  of  Berkley,10  Simmons,11 
and  Schlimpert12  show  that  among  12,114  autopsies  upon  tuberculous 
women,  genital  tuberculosis  was  present  in  215  subjects,  but  in  none 
was  the  external  genital  involved.  In  1903  Berkley10  was  able  to  find 
in  the  literature  but  four  which  were  above  suspicion. 

Varieties. — In  general,  vulvar  lesions  closely  resemble  tuberculosis 
of  the  skin  in  other  parts  of  the  body,  except  that  they  are  often  modified 
as  a  result  of  local  conditions,  such  as  moisture  discharge,  heat,  friction 
and  the  presence  of  special  glands  and  other  anatomic  conditions. 

Bender  13  and  Patel 14  recognize  two  forms  of  tuberculosis  of  the 
external  genitalia — the  ulcerative  and  hypertrophic.  Of  these,  the  ulcera- 
tive is  by  far  the  most  frequent.  Of  the  fifty-four  cases,  the  abstracts 
of  which  may  be  found  in  the  following  pages,  forty-four  were  of  this 
type  and  only  ten  of  the  hypertrophic  variety.  Bender  13  found  the  ul- 
cerative variety  almost  ten  times  as  frequent  as  the  hypertrophic.  Occa- 
sionally the  hypertrophic  form  undergoes  ulceration,  generally  upon 
the  prominence  of  the  tumor,  under  which  circumstances  the  cases  are 
usually  tabulated  as  ulcerative.  The  majority  of  the  ulcerative  lesions 
are  associated  with  more  or  less  swelling.  To  the  ulcerative  and 
hypertrophic  varieties  Combeleran  15  adds  a  third  variety,  which  he  des- 
ignates as  lupus  vulvae;  this  is  characterized  by  thickening  of  the  skin 
and  mucous  membrane,  occasionally  taking  on  a  verrucous  aspect,  or  by 
the  development  of  ulcerations  of  limited  depth  and  extent,  but  sometimes 
without  ulcerative  process.  This  is  a  doubtful  variety,  and  probably  mere- 
ly slightly  atypical  form  of  either  the  ulcerative  or  hypertrophic  form. 

Formerly,  much  confusion  existed  regarding  the  hypertrophic  variety 
and  many  cases  of  elephantiasis  and  other  forms  of  enlargement  were 
considered  of  tuberculous  origin.  The  contrary  also  probably  occurs, 
and  this  would  seem  especially  likely  in  view  of  the  difficulty  often 
encountered  in  correctly  diagnosing  the*  hypertrophic  form,  even  after 
a  careful  histologic  examination. 

Symptoms. — The  symptoms  resulting  from  lesions  of  the  external 
genitalia  are  in  themselves  generally  not  very  severe  and  in  the  secondary 
variety  are  usually  subservient  to  those  resulting  from  the  primary  condi- 
tion. Not  infrequently  there  is  a  history  of  previous  injury,  this  being 
particularly  likely  to  be  the  case  in  the  secondary  variety.  Thus,  a  fall 
from  a  horse,  which  resulted  in  injury  to  the  vulva,  occurred  in  the 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA 


in 


Bender  and  Nandrot 16  case,  and  the  history  of  a  fall  resulting  in  trauma 
to  the  vulva  was  also  present  in  the  case  recorded  by  Deschamps.17  In 
many  of  the  cases  a  tuberculosis  of  the  upper  genital  tract  can  be  dem- 
onstrated, and  not  infrequently  lesions  of  the  lungs  or  other  portions  of 
the  body  are  present.  Perhaps  most  frequently  of  all,  tuberculosis  of 
the  external  genitalia  is  secondary  to  intestinal  lesions.  In  the  author's 
case  the  disease  was  secondary  to  tuberculosis  of  the  hip  joint.  Thus, 
it  is  seen  that  the  condition  may  result  from  a  hematogenous  infection, 
from  direct  implantation  through  tubercle  bearing  discharges,  or  even 
from  exogenous  microorganisms,  and  from  a  direct  extension  from 
adjacent  foci.  In  Schenk's  18  case  the  child  had  long  associated  with 
two1  playmates  known  to  be  tuberculous. 

It  is  probable  that  direct  inoculation  from  sexual  intercourse  may 
occur.  The  infection  almost  certainly  came  from  a  tuberculous  husband 
in  Rieck's  19  case,  and  probably  in  Montgomery's.20  The  experiments 
of  Spano,21  PopO'ff,22  and  Gorovitz  23  bear  out  this  assertion.  Cornet 24 
suggests  that  tubercle  bacilli  bearing  saliva  may  be  used  as  a  lubricant 
by  a  phthisical  husband  during  coitus  and  thus  result  in  infection.  In 
a  previous  chapter  the  modes  of  direct  inoculation  have  been  more 
thoroughly  considered;  it  is  sufficient  here  to  state  that  in  the  case  of  a 
woman,  the  wife  of  a  tuberculous  husband,  there  are  other  and  more 
probable  channels  of  infection  than  the  genital  tract,  although  the  pos- 
sibility of  this  occurring  must  be  considered,  and  should  be  guarded 
against. 

While  the  number  of  cases  of  tuberculosis  of  the  external  genitalia 
tract,  recorded  in  literature,  is  as  yet  too  small  to  draw  definite  con- 
clusions from  regarding  many  of  the  symptoms,  it  would  appear  that 
no  age  is  immune. 

Among  39  cases,  the  average  age  was  31.82  years.  The  extremes 
are  13  months  (Demme25)  and  88  years  (Dambrin  and  Clermont26). 
Arranged  in  decades,  these  thirty-nine  cases  show  the  following: 


Years 


1 — 10 
11 — 20 

21—30  .... 

31—40  .... 

41—50  

51—60  .... 

61 — 70  .  .  .  . 

71  and  over 


Cases     Per  Cent 


7 

18.2 

4 

10.2 

8 

20.5 

12 

30.7 

1 

2-75 

4 

10.2 

1 

2-75 

2 

5-i 

ii2        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

A  family  history  of  tuberculosis  is  frequently  obtainable,  and  a 
history  of  previous  or  present  tuberculous  lesions,  such  as  pulmonary 
phthises,  intestinal  tuberculosis,  adenitis,  bone  lesions,  or  pelvic  inflam- 
matory disease,  is  often  present.  Both  single  and  married  women  are 
attacked,  the*  disease  apparently  exhibiting  no  marked  predisposition  in 
this  respect,  thus  bearing  out  what  has  already  been  said  regarding  the 
relative  infrequency  of  direct  inoculation  in  this  locality.  For,  if  direct 
implantation  by  means  of  coitus  often  resulted  in  genital  lesions,  tuber- 
culosis of  not  only  the  external  genitalia,  but  also  of  the  vagina  and  cervix, 
would  be  more  frequent  among  married  women  than  among  spinsters. 
This,  however,  is  not  the  case  to  any  marked  extent.  Parturition,  how- 
ever, appears  to  play  some  part  as  a  causative  agent.  In  the  secondary 
variety  it  is  certainly  a  not  unimportant  factor.  It  is  accepted  that  the 
parturient  woman  is  especially  susceptible  to  acute  miliary  tuberculosis, 
a  form  of  infection  in  which  secondary  lesions  of  any  sort  are  not 
uncommon.  Pregnancy  and  parturition  also  exert  an  unfavorable  influ- 
ence on  almost  any  form  of  tuberculosis,  especially  the  pulmonary  vari- 
eties, frequently  leading  to  exacerbation.  It  is  in  acute  infections  that 
secondary  genital  lesions  are  most  common.  On  the  other  hand,  in 
the  secondary  variety  of  genital  tuberculosis,  trauma  is  a  decided  predis- 
posing factor  and  the  trauma  incident  to  labor  or  miscarriage  must, 
therefore,  be  considered  apart  from  the  fact  that  in  the  parturient  state 
women  are  peculiarly  susceptible  to  any  form  of  infection.  Mont- 
gomery,29 Jorfida,27  and  Davidson  28  have  recorded  the  history  of  cases 
which  occurred  shortly  after  delivery.  The  results  of  animal  experi- 
mentation, which  have  been  previously  quoted,  show  that  trauma  and 
inflammation  are  predisposing  factors  to  direct  infection  as  well  as  to 
the  secondary  or  metastatic  variety. 

The  onset  of  tuberculous  lesions  of  the  external  genitalia  is  generally 
slow,  but  progressive.  Local  discomfort,  pain,  discharge,  and  frequent 
and  more  or  less  marked  dysuria  are  usually  the  most  prominent  symp- 
toms; but  even  these  are  quite  variable.  In  some  cases  the  pain  is 
quite  marked  and  in  others  it  is  absent.  The  pain  may  be  sharp  and 
cutting  in  character  or  a  dull  ache.  Most  frequently,  as  the  disease 
advances,  the  pain  becomes  more  pronounced,  and  if  the  lesion  is  of 
the  ulcerative  variety  and  so  situated  that  the  urine  flows  over  it,  pain 
at  or  following  micturition  is  nearly  always  observed.  The  rubbing 
of  the  clothing  against  the  ulcer,  coitus,  or  other  trauma  is  frequently 
complained  of.  Not  infrequently  there  is  intense  pruritus  and  more  or 
less  itching  is  generally  present,  as  in  the  cases  of  Deschamps,17  Renaud,29 
and  Martin.30     In  the  hypertrophic  variety  the  pain  is  less  marked,  the 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  113 

enlargement,  however,  from  its  very  size,  may  produce  discomfort.  In 
the  ulcerative  variety  discharge  is  nearly  always  present.  This  varies, 
according  to  the  stage  and  character  of  the  lesions,  from  a  thick,  purulent 
secretion  to  a  thin,  more  or  less  irritating  leukorrhea.  In  acute  cases 
or  following  trauma,  it  may  be  blood  streaked.  As  a  result  of  the  dis- 
charge, a  more  or  less  general  vulvitis  usually  occurs  and  sometimes  pro- 
duces distressing  symptoms,  a  certain  amount  of  pruritus  being  almost 
always  present. 

Many  cases  being  secondary  to  tuberculosis  of  the  upper  genital  tract, 
it  is  difficult  to  determine  how  much  of  the  discharge  comes  from  above 
and  how  much  from  the  vulvar  lesion.  As  a  rule,  the  ulcers  do  not 
bleed  very  readily  to  the  touch  and  are  not  markedly  tender.  Tubercle 
bacilli  can  occasionally  be  demonstrated  in  the  discharge,  especially  if 
the  lesion  be  an  acute  one.  In  the  curettings  from  the  surface  of  the 
ulcers  they  can  frequently  be  found.  Occasionally,  as  a  result  of  exten- 
sion of  the  ulcer,  fistulas  form.  In  the  ulcerative  variety,  and  sometimes 
in  the  hypertrophic,  inguinal  adenitis  occurs.  Murphy 31  states  that 
inguinal  adenitis  occurs  late.  This,  however,  depends  largely  upon  the 
character  and  location  of  the  lesion  and  upon  the  amount  of  suppuration 
present. 

Appearance  of  the  Ulcerative  Variety. — This  is  generally  pre- 
ceded and  accompanied  by  more  or  less  enlargement.  In  the  case  re- 
ported by  Bender  and  Nandrot 16  the  condition  began  as  a  fluctuant  swell- 
ing, which  finally  broke  down,  leaving  a  discharging  cavity  which  was 
extremely  chronic  in  type  and  which  exhibited  little  or  no  tendency 
towards  spontaneous  resolution.  The  areas  surrounding  the  preliminary 
swelling  are  usually  discolored  and  edematous.  The  adjacent  tissue  is 
indurated.  After  a  varying  length  of  time,  sometimes  many  months, 
the  swelling  softens  in  one  or  more  areas  and  breaks  down.  In  some 
cases  the  lesion  begins  as  one  or  more  small  firm  nodules,  which  subse- 
quently soften  and  break  down.  Thus  a  number  of  ulcers  may  be 
formed.  These  may  finally  coalesce,  forming  a  single  large  granulating 
area,  usually  covered  with  a  layer  of  necrotic  tissue.  The  ulcer  may 
originate  as  a  superficial  loss  of  tissue,  and  then  gradually  enlarges. 
The  ulcer  may  occur  on  any  part  of  the  external  genitalia,  but  is  perhaps 
most  frequently  on  the  labia  majora  or  minora.  One  or  both  sides  may 
be  involved,  and  contact  ulcers  on  the  opposite  side  are  occasionally 
observed.  The  ulcers  may  extend  backwards  into  the  vagina  or  out- 
wards over  the  skin,  perineum,  or  adjacent  structures.  When  the 
vagina  is  involved,  fistulas  connecting  with  the  various  adjoining  hollow 
viscera  are  not  infrequent  and  the  symptoms  from  these  are  likely  to  be 


ii4        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

a  marked  feature.  Occasionally  the  anus  is  involved.  Ulcers  of  the 
external  genitalia  vary  in  appearance ;  the  margins  are  often  elevated  and 
swollen  or  the  edges  undermined.  The  base  is  usually  moderately  firm 
and  may  be  covered  by  minute,  grayish  or  yellowish  elevations 
(tubercles).  In  some  cases  the  floor  of  the  ulcer  is  covered  by  a  dirty, 
yellowish  or  brownish  crust.  An  appearance  of  chronicity  is  common 
to  the  majority  of  these  lesions.  The  color  may  be  grayish,  yellowish, 
reddish  or  brownish,  and  the  surrounding  skin  is  often  chronically  in- 
flamed, discolored,  hyperemic,  and  may  contain  enlarged  veins.  The 
ulcers  vary  markedly  in  size.  Thus,  in  Legane's  32  case  the  entire  vulvar 
region,  including  the  hymen,  was  destroyed  by  a  yellowish  ulcer.  A 
somewhat  similar  case  is  recorded  by  Brault.33 

The  ulcers  are  often  serpiginous  in  character,  healing  behind  as  the 
advance  is  made.  As  a  result,  cicatrices  may  be  present.  In  some  in- 
stances, where  the  urethra  has  been  attacked,  the  disease  has  apparently 
followed  the  mucosa  of  that  canal,  forming  finally  a  funnel  shaped  ulcer 
with  the  small  end  directed  towards  the  bladder.  Reed  34  states  that 
frequently  the  meatus  appears  to  be  torn  laterally,  somewhat  after  the 
manner  of  the  Emmet  denudation  for  trachelorrhaphy,  while  on  the  other 
hand  almost  microscopic  lesions  have  been  described. 

Hypertrophic  Variety. — This  is  an  extremely  rare  form,  and  too 
few  cases  are  recorded  to  base  on  them  a  definite  description.  In  the 
cases  reported  by  Petit  and  Bender,  and  Poverlein  the  lesions  were 
characterized  by  moderately  large  tumor-like  masses,  which  in  Pover- 
lein's  case  were  at  first  mistaken  for  a  sarcoma  of  the  labia.  Specimens 
in  the  cases  of  Petit  and  Bender,  Forgue  and  Massabuau  resembled  an 
elephantiasis.  The  discharge  is  not  profuse  and  is  never  purulent  or 
sanguineous.     Tubercle  bacilli  have  never  been  demonstrated  in  it. 

Bulkley  3  gives  the  below  summary  regarding  the  parts  involved.  In 
this  summary  the  hypertrophic  and  ulcerative  varieties  are  included, 
from  which  it  will  be  seen  that  the  labia  are  most  frequently  involved. 

Parts  Involved  Cases 

Vulva 10 

Labia  majora 29 

Labia  minora 30 

Clitoris    8 

Entire  introitus 7 

Posterior  commissure 6 

Anterior  commissure 3 

Mons  veneris 2 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  115 

Parts  Involved  Cases 

Edge  of  urethra 5 

Bartholin's  gland 2 

Prepuce    1 

Diagnosis. — A  positive  diagnosis  without  the  aid  of  the  microscope 
in  either  the  ulcerative  or  hypertrophic  varieties  is  impossible.  Malignant 
tumors  and  syphilis  are  the  two  conditions  most  likely  to  cause  confusion ; 
although  in  children  gonorrheal  vulvovaginitis,  anovulvar  diphtheria,  and 
noma  vulvae  must  be  differentiated.  Chancroids  can  usually  be  readily 
differentiated,  as  can  kraurosis  vulvae.  The  hypertrophic  variety  usually 
more  or  less  closely  resembles  elephantiasis.  Bender 35  recommends 
biopsy  in  all  cases  in  which  there  is  ulceration,  but  even  this  is 
untrustworthy  in  the  hypertrophic  variety. 

The  Wassermann  reaction  should  be  applied  to  all  cases,  and  in  chil- 
dren the  von  Pirquet  reaction  will  be  of  value.  It  should  be  remembered 
that  malignant  neoplasms,  especially  in  the  aged,  are  far  more  frequent 
than  is  tuberculosis,  and  a  thorough  histologic  examination  to  exclude 
this  possibility  should  be  made  without  loss  of  valuable  time  in  all  cases. 
After  excision  of  the  suspected  area  the  diagnosis  can  usually  be  readily 
arrived  at.  Histologic,  bacteriologic,  and  animal  inoculation  will  clear 
up  all  doubtful  cases.  For  the  histologic  examination,  it  is  advisable 
to  examine  slides  from  a  number  of  sections,  as,  if  only  one  block  is 
taken,  characteristic  lesions  may  be  absent.  In  the  hypertrophic  form 
tubercles  are  sometimes  rare  and  only  the  bacilli,  and  these  in  small 
numbers,  are  found.  The  fact  should  not  be  lost  sight  of  that  syphilis 
or  malignant  tumors,  or  even  both,  may  accompany  tuberculosis. 

The  presence  of  tuberculosis  in  other  parts  of  the  body,  grayish 
tubercle  like  elevations  at  the  base  of  the  ulcer,  the  presence  of  acid  fast 
bodies  morphologically  similar  to  the  tubercle  bacilli  in  the  discharge, 
all  point  to  tuberculosis.  In  staining  for  tubercle  bacilli  the  smegma 
bacilli  must,  however,  be  excluded.  The  absence  of  a  syphilitic  history 
and  a  negative  Wassermann  reaction  will  practically  exclude  syphilis; 
while  the  longer  duration,  more  chronic  appearance  of  the  lesions,  and 
the  lessened  tendency  to  bleeding,  and  perhaps  the  age  of  the  patient,  are 
evidence  against  the  condition  being  a  malignant  tumor. 

Prognosis. — This,  as  in  all  tuberculous  lesions  of  the  female  genital 
tract,  depends  largely  upon  whether  the  lesion  be  a  primary  or  secondary 
one.  In  the  latter  event,  the  primary  focus  will  often  be  the  more  severe 
and  the  prognosis  will  naturally  depend  upon  its  location  and  character. 
In  some  cases  the  genital  lesions  are  extremely  chronic :  thus,  in  Pover- 


n6   GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 


lein's 36  case  the  disease  had  been  present  for  seventeen  years,  in 
Viatte's 37  case,  seven  years,  and  in  Montgomery's  20  case,  five  years ; 
whereas  in  other  reported  cases  rapid  dissemination  of  the  infection  and 
death  have  occurred.  Demme  25  emphasizes  the  rapid  course  that  the 
disease  may  follow,  especially  in  children.  A  lethal  termination  is, 
however,  rarely  due  to  genital  lesions  alone. 

Even  after  apparent  entire  excision,  recurrences  may  occur.  On  the 
other  hand,  spontaneous  healing  occasionally  takes  place,  but  this  is 
unusual.  More  frequently  the  course  of  the  disease  is  chronic,  but  pro- 
gressive. Unfortunately  the  great  majority  of  reports  are  either  too 
recent  or  mention  is  not  made  of  the  ultimate  outcome  of  the  cases. 
Statistics  are  thus  apt  to  be  misleading.  Bulkley  3  in  his  excellent  review 
of  tuberculosis  of  the  external  genitalia,  presents  the  following  table, 
but  warns  us  that  the  heading  "healed"  cannot  be  interpreted  as  an  end 
result : 


Method  of  Treatment 


Excision 

Curettage  and  cauterization 

Excision  with  cautery 

Cauterization    

Nitric  acid   

Iodoform 

Tuberculin 

General  hygiene 


1_         C/J 

<U      CD 
<-c        TO 

1° 


20 

6 
1 
1 

1 
2 
1 
1 


K 


13 

5 
o 

1 

1 

2 

1 

1 


i-t       CD 

3  a 


rt 


7 
1 . 

1 

o 

o 

o 

o 

o 


jv     u 


65 
83 
O 
IOO 
IOO 
IOO 
IOO 

IOO 


Treatment. — This  depends  largely  upon  whether  the  genital  lesion 
be  primary  or  secondary.  In  this  connection,  it  should  be  remembered 
that  in  some  cases  this  is  an  extremely  difficult  point  to  determine,  as 
the  manifestation  of  the  primary  lesion  may  be  insignificant  or  it  may 
have  even  undergone  partial  resolution.  Under  such  circumstances,  if 
the  primary  lesion  be  in  the  lungs  and  a  general  anesthetic  be  adminis- 
tered, the  pulmonary  condition  may  be  lighted  up  with  disastrous  results. 
The  utmost  care,  therefore,  should  be  exercised  and  an  extremely  thor- 
ough physical  examination  be  performed  to  determine  this  point.  Unfor- 
tunately, the  majority  of  cases  are  secondary,  the  primary  focus  usually 
being  in  the  lungs  or  intestines,  and  as  a  rule  easily  demonstrated.  The 
fact,  which  has  been  pointed  out  under  the  heading  of  diagnosis,  that 
in  many  cases  tuberculous  lesions  of  the  external  genitalia  closely  simulate 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  117 

malignant  neoplasms  or  syphilis,  and  the  greater  frequency  of  these 
conditions,  should  in  all  cases  lead  to  the  exclusion  of  these  as  a  primary 
step. 

If  the  Wassermann  reaction  be  negative,  a  diagnostic  excision  of  all, 
or  at  least  of  part,  of  the  suspected  lesion  should  be  performed 
without  delay,  for  the  purpose  of  excluding  malignant  tumors.  An 
exception  to  this  may  exist  in  certain  cases  in  early  life  and  in  those 
cases  in  which  the  patient  is  clearly  doomed  as  a  result  of  an  advanced 
primary  lesion.  The  diagnostic  excision  may,  if  it  is  thought  advisable, 
be  performed  under  local  anesthesia,  and  the  cautery  knife,  heated  to  a 
dull  red,  should  be  employed.  Bloodgood  38  has  shown  that  in  cases  of 
malignant  tumors  excision  of  the  suspected  area  with  the  cautery  knife, 
heated  to  a  dull  red,  or  immediate  cauterization  of  the  wound  after 
excision  is  much  less  likely  to  be  followed  by  dissemination.  If  the 
lesion  is  small  or  easily  removed,  it  is  preferable  to  excise  in  toto  and 
thus  exclude,  as  fully  as  can  be  done,  the  possibility  of  this  danger. 

The  general  trend  of  the  modern  scientific  opinion  is  towards  surgery 
in  the  treatment  of  these  cases,  followed  by  general  hygienic  measures, 
preferably  carried  out  in  a  sanitarium.  In  all  cases  the  anesthetic  should 
be  chosen  with  great  care  and  it  is  a  safe  rule  in  this  respect  to  treat 
all,  even  supposedly  primary  cases,  as  if  they  were  the  incumbents  of  a 
lung  lesion.  In  all  cases  a  thorough  pelvic  examination  should  be 
performed  to  determine  whether  adnexal  lesions  are  present. 

The  treatment  naturally  divides  itself  into  that  of  the  primary  and 
secondary  cases,  and  into  a  third  class  in  which  this  point  cannot  be 
positively  determined. 

Primary  Variety. — In  these  cases  a  radical  extirpation  is  indicated. 
The  character  of  the  operation  will  naturally  vary  with  the  individual 
case,  but  an  attempt  should  always  be  made  to  excise  a  wide  margin  of 
healthy  tissue.  Except  in  the  aged,  care  must  be  exercised  not  to  unduly 
narrow  the  vaginal  orifice.  In  some  cases,  when  the  lesions  are  extensive, 
plastic  operations  to  supply  the  excised  tissues  may  be  necessary. 
Excision  of  the  inguinal  lymphatic  glands,  if  these  are  enlarged  or  have 
given  symptoms,  should  be  a  part  of  the  operation.  The  question  of 
the  excision  of  the  glands,,  when  these  are  not  enlarged  or  have  not 
produced  symptoms,  is  still  undecided.  Under  the  latter  circumstances 
probably  the  best  course  to  pursue  is  to  cease  the  operation  after  the 
excision  of  the  genital  lesion  and  keep  the  patient  under  observation. 
Should  the  histological  examination  reveal  a  malignant  tumor  instead 
of  tuberculosis,  the  glands  may  be  excised  at  a  second  sitting,  and  if 
necessary  a  wider  excision  of  the  genital  lesions  can  be  performed. 


n8   GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Secondary  Variety. — The  treatment  of  these  cases  depends  largely 
upon  the  character  of  the  primary  lesion  and  the  severity  of  the  symptoms 
produced  by  the  genital  condition.  No  hard  and  fast  rule  can  be  formu- 
lated for  the  treatment  of  this  class  of  cases,  each  of  which  must  be 
judged  individually.  If  the  primary  lesion  is  mild  and  the  general  condi- 
tion good,  total  excision  of  the  genital  process  is  almost  always  indicated. 
The  location  of  the  trouble,  its  size,  mobility,  rapidity  of  growth,  the 
amount  of  discomfort  that  it  is  producing,  the  character  of  the  operation 
required,  and  more  especially  the  variety  and  location  of  the  primary 
lesion  and  the  general  condition  of  the  patient,  are  all  factors  which  must 
be  taken  into  consideration. 

In  the  majority  of  the  secondary  cases  excision  of  the  genital  lesion 
is  advisable  for  three  reasons,  (i)  for  its  palliative  effect,  (2)  exclusion 
of  malignant  tumors,  (3)  the  primary  lesion  may  subsequently  be  cured. 
If  excision  is  rejected,  curettage  and  cauterization  of  the  ulcerative 
variety  should  usually  be  performed.  After  curettage  a  free  application 
of  the  thermocautery  is  advisable;  if  this  is  impossible,  application  of 
phenol  or  the  pure  tincture  of  iodin,  the  latter  repeated  daily  for  five 
or  six  days,  is  indicated.  Patal 14  recommends  the  application  of  lactic 
acid  and  employs  this  in  all  cases  in  which  total  excision  cannot  be  per- 
formed. Veit 39  strongly  recommends  iodoform  as  a  palliative  agent. 
Bender 13  urges  excision  for  its  palliative  effect  in  nearly  all  cases. 
Especially  is  excision  indicated  in  the  hypertrophic  form  of  the  disease. 

Doubtful  Cases. — Occasionally,  as  has  been  mentioned,  cases  will 
be  encountered  in  which  it  is  impossible  to  determine  whether  they  are 
primary  or  secondary,  even  after  a  thorough  examination.  These  cases 
should  be  treated  as  if  they  were  of  the  primary  variety  and  the  same 
precautions  employed  to  prevent  the  lighting  up  of  a  primary  focus  in 
the  lungs  or  elsewhere,  as  if  such  lesion  were  known  to  exist. 

The  Rontgen  rays,  either  alone  or  following  operation,  have  appar- 
ently produced  excellent  results  in  some  cases  and,  on  account  of  the 
danger  of  local  recurrence,  may  be  employed  routinely  following 
excision,  especially  if  the  operation  has  been  performed  for  a  primary 
lesion.  Radium  has  been  employed  by  some  authorities,  with  favorable 
results.  The  question  of  anesthesia  in  tuberculous  patients  will  be  con- 
sidered more  fully  in  a  subsequent  chapter.  Strauss  40  employs  prep- 
arations of  copper  locally  in  cases  of  skin  tuberculosis.  He  believes 
that  they  not  only  possess  a  caustic  action,  but  that  they  exercise  a 
specific  effect  on  the  tubercle  bacilli.  He  recommends  the  new  copper 
compounds,  especially  in  combination  of  lecithin  and  copper,  and  also 
methylene  blue. 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  119 

General. — As  in  all  forms  of  genital  tuberculosis,  whether  primary 
or  secondary,  but  especially  in  the  latter,  it  is  of  the  utmost  importance 
that  thorough,  systematic  treatment  be  directed  towards  the  improve- 
ment of  the  general  health.  It  is  imperative  that  the  reactive  powers  of 
the  patient  be  strengthened  as  much  as  possible.  General  hygienic 
measures,  such  as  regular  life,  outdoor  living,  forced  feeding,  particu- 
larly eggs  and  milk,  regulation  of  the  bowels,  and  perhaps  the  exhibition 
of  a  tonic,  should  be  employed.  If  the  case  is  a  secondary  one,  this  is 
especially  important,  and  appropriate  treatment  should  be  directed  toward 
the  primary  lesion.  The  danger  of  infection  should  be  avoided  as  much 
as  possible  and  all  predisposing  inflammatory  causes  treated  energet- 
ically. Patal 14  states  that  in  some  cases  vaccine  exerts  a  beneficial  influ- 
ence. For  a  full  discussion  of  the  postoperative  case,  the  reader  is 
referred  to  a  subsequent  chapter. 

The  following  is  a  list  of  cases  of  tuberculosis  of  the  external  gen- 
italia. As  many  of  these  cases  are  associated  with  vaginal  tuberculosis, 
the  list  of  cases  of  tuberculosis  of  the  latter  region  should  also  be 
consulted. 

CASE  HISTORIES 

Petit  and  Bender.35,41  Tuberculous  Hypertrophy,  Non-Ulcerative, 
of  the  Vulva.  Patient,  aged  thirty-one  years  and  single,  had  a  mis- 
carriage eight  years  before  admission  for  treatment,  and  later  a  seven 
months  child  that  died.  Two  months  ago  the  patient  was  delivered 
of  a  child,  with  forceps.  During  pregnancy  she  had  menstruated  as 
usual.  The  vulva  became  uniformly  enlarged  during  the  first  gesta- 
tion. The  enlargement  was  progressive  but  somewhat  subsided,  follow- 
ing the  puerperium.  The  patient  first  noticed  the  vegetations  during  the 
third  pregnancy.  The  labia  majora  became  enlarged  but  did  not  change 
in  color  and  seemed  to  be  the  seat  of  an  edema.  The  labia  minora,  the 
hood  of  the  clitoris,  and  the  outlet  of  the  meatus  appeared  transformed 
into  a  vegetating  tissue  of  dull  red  color,  and  of  firm  consistency.  At 
the  site  of  the  carunculae  were  four  warty  tumors  that  fused  together  and 
that  partially  masked  the  entrance  of  the  vagina  and  the  urethra.  Poly- 
poid hypertrophy  of  the  ureteral  mucosa  was  also  present.  The  lower 
part  of  the  right  labium  minus  was  covered  with  large  verrucosities,  as 
with  millet  or  lentil  seeds.  No  ulcerations  whatsoever  were  present. 
No  pain  or  functional  signs,  except  frequent  and  involuntary  micturition, 
were  observed.  Internal  pelvic  examination  proved  negative,  as  were 
the  lungs.  Excision  and  recovery.  Histologic  and  bacteriologic  con- 
firmation of  the  diagnosis  was  obtained. 


120        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Bender  and  Nandrot.10  Woman,  aged  thirty-nine  years,  had  cervical 
adenitis  in  childhood.  Two  years  ago  the  patient  sustained  a  fall  from 
a  horse,  after  which  a  cystic  tumor  gradually  formed  on  the  vulva. 
Nearly  a  year  after  the  fall  the  cyst  broke  spontaneously.  The  contents 
were  found  to  be  sanguineous,  but  no  pus  was  present  in  the  early  stages. 
The  lesion  was  extremely  chronic,  discharged  profusely,  and  after  .six 
months  the  discharge  became  purulent.  At,  the  same  time  sharp,  lancinat- 
ing pains  occurred  in  the  vulvar  region.  Menstruation  became  irregular, 
the  patient  lost  general  strength,  and  became  emaciated.  Both  labia 
majora  were  much  hypertrophied.  A  hard,  reddish  purple  enlargement, 
the  size  of  a  nut,  was  found  at  the  lower,  left  labium  majus.  This  had 
two  small,  fistulous  openings,  which  discharged  yellowish  green  pus. 
A  similar  formation  existed  on  the  lower  part  of  the  right  labium  majus. 
A  small  piece  of  tissue  was  excised  and  a  diagnosis  of  tuberculosis  made. 
Fungous  masses  were  found  on  the  inner  surface  of  the  lesion  and  were 
removed.  A  sound  introduced  into  the  wound  came  out  in  the  vagina 
about  2  cm.  above  the  vaginal  orifice.  The  histological  examination 
showed  that  the  epithelium  was  hypertrophied  and  very  voluminous.  The 
skin  was  thickened,  edematous,  and  contained  collections  of  leukocytes 
under  the  epithelium  and  around  the  vessels.  At  the  site  of  the  ulceration, 
the  epithelial  layer  was  suddenly  interrupted,  forming  a  dome  shaped  de- 
pression partly  filled  by  leukocytes  and  fibrin.  The  base  of  this  ulceration 
was  formed  by  granulation  tissue  and  typical  tubercles  with  giant  cells 
were  present.  Tubercle  bacilli  were  also  demonstrated.  The  leukocytes 
were  mostly  polynuclear ;  plasma  cells  and  mast  cells  were  also  observed. 
Both  labia  were  affected,  being  considerably  thickened  (2  or  3  cm.).  The 
surface  was  irregular  and  the  skin  drawn  up  into  numerous,  minute, 
wrinkled  folds.  A  small  nodule,  about  2  cm.  in  diameter,  was  found  on 
the  right  labium.  An  analogous  formation,  but  somewhat  more  massive, 
was  found  on  the  left  labium.  The  hood  of  the  clitoris  was  thickened 
and  indurated,  and  the  mucosa  about  the  urethra  was  somewhat  discol- 
ored. The  clitoris  itself  was  not  involved.  Histological  examination 
showed  the  skin  intact,  although  thinned  in  places  and  thickened  in 
others.  The  lower  layers  of  skin  and  subjacent  tissue  were  made  up  of 
cellular  tissue  with  numerous  blood  vessels  and  large  lymphatic  vessels. 
This  tissue  was  abundantly  infiltrated  with  leukocytes,  a  layer  of  which 
involved  the  stratum  immediately  subjacent  to  the  epithelium.  Beneath 
the  skin  and  in  the  subcutaneous  tissue,  the  leukocytes  were  arranged 
in  the  form  of  perivascular  accumulations.  The  polymorphonuclear  ele- 
ments were  in  the  majority,  but  there  were  also  numerous  plasma  cells 
and  mast  cells.    Tubercles  with  tuberculous  giant  cells  were  present,  some 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  121 

being1  in  the  superficial,  cellular  tissue  and  some  in  the  deeper  layers. 
Typical  bacilli  were  demonstrated  in  the  tubercles.  Sections,  stained  for 
elastic  tissue  by  the  orcein  method,  showed  that  this  had  been  dissociated 
by  connective  tissue. 

Lecene.42  Tuberculosis  of  Bartholin's  Gland.  Case  1.  Patient, 
aged  forty  years,  previously  had  an  hysterectomy  performed  for  cancer 
of  the  cervix.  The  author  believes  that  the  tumor  may  really  have  been 
tuberculous  and  mistaken  for  cancer.  Eighteen  months  afterwards  the 
patient  consulted  the  surgeon,  who  had  performed  the  operation,  for  the 
relief  of  a  small,  hard  tumor  on  the  labium  majus.  This  was  extirpated 
and,  on  histological  examination,  showed  tuberculosis  of  the  gland.  The 
secreting  acini  and  excretory  ducts  were  normal.  There  was  a  peri-acinal 
and  interlobular  inflammation  separating  the  acini.  The  interacinal  tissue 
was  well  supplied  with  blood  vessels.  Tuberculous  follicles  with  giant 
cells  and  tubercle  bacili  were  found  at  the  edges  of  the  glands.  Especially 
evident  was  the  peri-acinal  and  perilobular  distribution  of  the  lesion,  a 
distribution  that  would  seem  to  point  to  a  blood  infection,  and  not  an 
infection  through  the  excretory  duct. 

Case  2.  Woman,  aged  twenty-three  years,  had  bilateral  inguinal 
adenitis,  which  was  painful  and  in  the  subacute  stage.  It  appeared  first 
on  the  right,  then  on  the  left.  A  glandular  swelling,  the  size  of  a  hen's 
egg,  was  found  in  the  right  groin.  It  was  reddish  purple  in  color  and 
hard,  with  areas  of  softening.  In  the  left  groin  was  a  mass  the  size 
of  a  pigeon's  egg,  non-adherent,  movable  on  the  subjacent  tissues,  and 
slightly  painful.  There  was  a  fistula  external  to  the  sphincter,  about  five 
centimeters  from  the  anus,  in  the  middle  line,  posteriorly.  The  labium 
minus  on  the  right  presented  an  ulceration  at  the  union  of  its  inferior 
third  and  its  superior  two  thirds.  The  ulceration  was  the  size  of  a  franc 
piece  and  was  parallel  to  the  course  of  the  lip.  The  base  was  not  in- 
durated and  the  ulcer  not  secreting  freely.  At  the  seat  of  Bartholin's 
gland  was  a  swelling  the  size  of  a  small  nut.  Examination  of  the  secre- 
tion from  the  base  of  the  ulcer  showed  tubercle  bacilli.  The  glands, 
ulcer,  etc.,  were  extirpated.  Microscopic  examination  of  the  glands 
showed,  in  places,  a  peri-acinal  lymphocytic  and  perifollicular  lympho- 
cytic infiltration,  also  giant  cells.  Bartholin's  gland  presented  the  pic- 
ture of  a  hematogenous  infection. 

Nogues.43  Girl,  fourteen  years  of  age.  Father  died  of  suppurating 
inguinal  fistulas.  Some  of  her  sisters  died  of  bronchitis.  At  two  years 
of  age  she  had  meningitis,  which  left  her  with  suppurating  ears,  almost 
complete  deafness,  and  nocturnal  enuresis.  For  the  first  time,  eight 
months  before  consulting  a  surgeon,   the   patient  was   found  to  have 


122        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

straining  at  micturition  and  increase  of  urination,  with  almost  persistent 
nocturnal  incontinence.  Gonococci  were  found  in  the  vulvar  discharge. 
There  was  a  tuberculous  involvement  of  the  labia.  Attempts  to  demon- 
strate tubercle  bacilli  by  staining  methods  failed.  The  diagnosis  was 
however  verified  by  animal  inoculation. 

Renaud.29  Tuberculous  Ulcer  of  the  Labium  Majus — Primary. 
Child,  aged  four  years,  presented  a  reddish  blue  discoloration  and  a  fluc- 
tuant swelling  of  the  left  labium  majus.  Palpation  was  not  very  painful. 
An  ulcer,  found  in  the  superior  part  of  the  lip,  lays  bare  the  canal  of 
Nuck  and  the  round  ligament.  The  edges  of  the  ulceration  are  infiltrated, 
clear  cut,  and  reddish  purple  in  color,  The  base  is  grayish  yellow  and 
covered  with  a  sanious  secretion.  This  ulceration  meets  the  lesser  lip 
and  in  the  interlabial  sulcus  are  two  whitish  yellow  areas  resembling 
grains  of  sago.  The  glands  of  the  groin  are  small,  hard,  and  indurated. 
Examination  of  the  secretion  showed  tubercle  bacilli  and  colon  bacilli. 
The  ulcer  was  treated  with  tincture  of  iodin  and  a  dressing  of  iodoform 
was  applied.  The  ulcer  healed,  after  the  disappearance  of  the  tubercle 
bacilli,  and  the  child's  health  remained  good.  There  had  been  no  tuber- 
culosis in  the  family,  and  the  child  was  not  otherwise  affected  with  this 
disease.    The  case  began  as  an  erythema  of  the  affected  parts. 

Dambrin  and  Clermont.26  Patient,  aged  eighty-eight  years.  Nothing 
bearing  on  the  subject  of  tuberculosis  was  found  in  the  personal  history, 
except  a  pneumonia  at  the  age  of  forty-five  years.  She  consulted  a 
physician  for  an  enlargement  of  the  vulva,  which  had  been  present 
for  about  eight  months.  There  was  no  pain,  except  for  occasional  lanci- 
nating pains  in  the  tumor.  The  tumor  in  the  right  labium  majus  was 
egg  shaped,  smooth,  and  regular,  a  little  painful  to  pressure,  and  non- 
adherent to  the  skin  or  deeper  layers.  It  did  not  seem  to  be  attached 
by  a  pedicle,  and  appeared  to  be  totally  contained  in  the  labium  majus. 
The  uterus  was  small  and  the  other  genital  organs  were  normal.  An 
incision  fnto  the  tumor  while  attempting  its  removal  showed  it  to  contain 
grumous  pus.  It  was  a  cold  abscess  secondary  to  a  bone  disease  of  the 
anterior  surface  of  the  os  pubis.  The  case  was  remarkable  because  of 
its  rarity,  the  difficulties  of  diagnosis,  the  age  of  the  woman,  and  because 
the  abscess  did  not  open  spontaneously. 

Wolff.44  Patient,  aged  fifty-one  years,  had  an  ulcer  on  the  left  labium 
majus  one  half  year  before  examination.  A  clinical  diagnosis  was  im- 
possible, but  tuberculosis  was  recognized  microscopically.  The  patient 
had  formerly  had  a  tuberculous  tenosynovitis  of  the  right  hand  and  also 
pulmonary  tuberculosis  with  bacilli  in  the  sputum.  The  vaginal  introitus 
was  unaffected. 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  123 

Legane.32  Girl,  six  years  of  age,  with  tuberculous  family  history. 
She  had  incontinence  of  urine  and  the  entire  vulvar  region,  including 
the  hymen,  was  occupied  by  a  yellowish  ulceration.  The  urethral  orifice 
was  completely  destroyed  by  the  ulceration.  The  kidneys  were  not  pain- 
ful nor  palpable.  Tubercle  bacilli  were  found  in  the  urine.  The  child 
died  of  pulmonary  tuberculosis.  At  autopsy  one  kidney  and  bladder  were 
found  to  be  tuberculous. 

Winter.45  This  patient  had  an  ulcer  with  a  lardaceous  base  on  the 
interior  surface  of  the  labia  minora.  The  adjacent  mucous  membrane 
was  red  and  infiltrated.  A  rectal  fistula  was  also  present.  On  histological 
examination  tuberculosis  and  tubercle  bacilli  were  found. 

Schenk.18  Girl,  four  and  a  half  years  of  age,  had  a  large  ulcer  of 
the  vaginal  orifice  which  involved  the  labia  minora,  the  clitoris  and  the 
urinary  meatus.  Considerable  edema  and  hypertrophy  were  present.  An 
inguinal  adenitis  was  present.  The  child  had  two  tuberculous  playmates 
and  Schenk  believes  that  the  infection  occurred  from  their  fingers.  The 
family  history  was  negative  for  tuberculosis.  Histological  examination 
of  the  ulcer  and  of  the  glands  showed  tubercle  bacilli  in  both. 

Kiittner.46  Girl,  four  and  a  half  years  of  age,  with  whooping  cough. 
No  tubercle  bacilli  were  found  in  the  sputum.  There  was  hard  in- 
duration of  the  right  labium  majus,  with  ulcerative  involvement  of  the 
upper  two  thirds.  Smaller  ulcerations  were  present  on  mons  veneris  and 
the  upper  part  of  the  left  labium  majus.  Biopsy  and  diagnosis  of  tuber- 
culosis. The  ulcer  and  enlarged  inguinal  glands  were  excised.  Histo- 
logical examination  of  the  ulcer  and  of  the  inguinal  glands  showed  the 
lesions  to  be  tuberculous.  Child  in  good  health  three  months  after  the 
operations. 

Gebbard.47  The  patient  had  a  small,  ulcerated,  soft  tumor  the  size 
of  a  cherry  seed,  on  the  vulva.  A  small  ulcer  developed  and  involved 
the  external  urinary  meatus.  The  tumor  was  about  as  hard  as  a  wart. 
The  outgrowth  showed  the  histological  characteristics  of  tuberculosis. 

Martin.30,48  Case  1.  This  was  one  of  typical  tuberculous  ulceration 
of  the  labia  minora.  The  diagnosis  was  made  by  histologic  examination 
Patient,  aged  twenty-three  years  of  age,  presented  a  tumor  of  the  vulva. 
She  had  vaginitis  at  fourteen  years  of  age,  after  which  the  left  labium 
minus  began  to  swell  and  become  red,  hard  and  painless.  The  patient 
began  to  lose  weight.  Phthisis  was  present  at  the  apex  of  the  left  lung. 
An  ulcer  was  found  in  the  sulcus  between  the  left  labia  minus  and  majus, 
which  bled  easily.  The  hood  of  the  clitoris  was  hvpertrophied  and 
another  small  ulcer  was  present  between  the  right  labia  majus  and  minus. 
The  entire  vulva  was  edematous.     There  were  small  tumors,  about  the 


124        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

size  of  nuts,  on  the  raphe  and  around  the  anus.  These  latter  somewhat 
resembled  hemorrhoids.  A  rectovaginal  fistula  and  adenitis  of  the 
right  inguinal  glands  were  present.  At  autopsy  the  tumor  resembled 
elephantiasis.  Tubercles  and  tubercle  bacilli  were  found  in  the  vulva. 
The  author  believes  that  this  is  the  first  case  of  this  kind  in  which 
tubercle  bacilli  have  been  demonstrated. 

Case  2.  The  patient  was  thirty-two  years  of  age.  Both  right  labia 
were  involved,  especially  the  labium  ma  jus.  A  reddish  tumor-like  out- 
growth, the  size  of  an  apple,  was  present.  The  surface  was  wrinkled 
and  wart-like,  especially  the  inner  aspect.  The  left  labium  was  also 
enlarged.  The  condition  caused  considerable  pain  and  much  itching. 
The  vagina  was  involved  and  the  inguinal  glands  enlarged.  Excision 
was  practiced  and  histologic  verification  of  the  diagnosis  was  obtained. 
Recovery. 

Montgomery.20  Patient,  aged  thirty  years.  Colored.  Married. 
She  had  a  negative  family  history,  but  tuberculosis  was  present  in  the 
husband's  family.  The  menstruation  was  regular,  had  four  children  and 
one  miscarriage.  The  genital  symptoms  began  ten  years  ago.  Both 
labia  became  enlarged,  especially  the  right.  On  the  inner  surface  of  the 
vulva  was  an  ulcer,  one  fourth  inch  deep  and  one  third  inch  wide,  which 
extended  from  the  posterior  surface  of  the  vagina  forward  to  the  external 
genitalia.  Considerable  edema  was  present.  This  and  part  of  both  labia 
were  excised,  and  the  histologic  examination  showed  them  to  be 
tuberculous. 

Chiari.49  Woman  of  thirty  years  had  phthisis,  of  which  she  died. 
At  autopsy,  general  tuberculosis  was  found.  The  lungs  were  extensively 
involved  and  there  were  ulcers  in  the  rectum.  The  tubes,  ovaries,  and 
uterus  were  normal.  There  was  edema  of  the  labium  ma  jus  and  of  the 
vulvar  region.  A  large  ulcer  was  present  on  the  right  labium  ma  jus, 
extending  to  the  labium  minus  and  to  the  skin,  clitoris  and  meatus.  The 
anus  also  presented  an  ulcer.  The  specimen  showed  the  typical  his- 
tological picture  of  tuberculosis,  and  the  specific  organisms  were  demon- 
strated. 

Viatte.37  The  patient  was  a  woman  thirty-two  years  of  age.  For 
seven  years  she  had  a  yellowish  purulent  leukorrhea,  varying  somewhat 
in  amount.  For  the  last  three  years  small  polypoid  growths  had  appeared 
on  the  vulva  and  in  the  neighborhood  of  the  external  urinary  meatus. 
Occasionally  these  fell  off  and  new  ones  appeared  in  their  place.  Upon 
removal  of  the  tumor  it  was  found  to  cover  an  ulcer  which  extended  into 
the  vagina.  The  ulcer  had  a  firm  base  and  a  yellowish  surface.  His- 
tologically, this  did  not  present  a  typical  tuberculosis,  but  scrapings  from 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  125 

the  ulcer  showed  tubercle  bacilli.    The  tuberculin  test  was  positive.     No 
phthisis  was  present. 

Deschamps.7  The  patient  was  a  woman  of  twenty-five  years  of  age 
in  the  last  stage  of  phthisis.  She  had  a  fall  and  injured  her  vulva,  which 
was  followed  by  swelling.  Four  months  later  a  deep  ulcer  developed, 
which,  at  the  time  of  examination,  occupied  the  left  labium  majus  and 
extended  backwards  as  far  as  the  fourchette.  The  chief  symptom  pro- 
duced by  the  genital  condition  was  itching,  which  was  marked.  A 
moderate  amount  of  discharge  and  slight  bleeding,  if  traumatized,  was 
also  present.  No  adenitis  was  observed.  The  lesion  was  excised  and 
its  tuberculous  character  proven  by  histologic  examination  and  animal 
inoculation.  A  tuberculous  ulceration  was  also  present  on  the  dorsum 
of  the  hand.  At  her  death  the  peritoneum  and  internal  genital  organs 
were  found  normal. 

Demme.25  A  child  of  thirteen  months  had  an  ulcer  of  the  left  labium 
minus.  Tubercle  bacilli  were  demonstrated  in  the  secretion  from  the 
ulcer.  The  patient  died  at  sixteen  months  of  age  of  tuberculous  menin- 
gitis. The  child's  mother  had  pulmonary  tuberculosis.  Autopsy  showed 
the  labial  lesions  to  be  tuberculous.  An  ulcer  of  similar  etiology  was 
also  found  in  the  vagina.  The  ulcers  were  irregular,  granular  and  red- 
dish. 

The  author  believes  this  case  to  have  been  one  of  primary  genital 
tuberculosis,  as  the  genital  lesions  appear  to  have  antedated  the  meningitic 
involvement  by  some  months. 

Rieck.19  The  patient's  family  history  was  negative  for  tuberculosis. 
Before  marriage  the  patient  presented  no  evidences  of  tuberculosis.  The 
husband  died  of  tuberculosis.  Some  time  after  marriage  the  external 
genitalia  showed  evidences  of  disease.  The  right  labium  majus  was  the 
seat  of  an  acute  tuberculous  inflammation,  and  on  the  left  labium  minus 
was  a  stellate  ulceration,  involving  the  introitus  on  the  left  side,  and  the 
labium  minus  was  elongated,  hypertrophied  and  perforated  by  ulcers 
with  sharply  cut,  raised  edges  in  two  places.  It  was  somewhat  con- 
dylomatous  in  appearance.  The  growth  of  the  ulcer  was  slow,  but  pro- 
gressive. The  elephantiasic  change  had  preceded  the  ulceration  by  some 
months.  The  lesions  were  excised,  and  tubercle  bacilli  were  demonstrated 
in  the  tissue  histologically. 

Kelly.50  Woman,  aged  fifty-five  years,  had  a  small,  triangular 
shaped,  eaten  out  ulceration  at  the  anterior  commissure,  which  had  been 
present  for  one  year.  On  urinating,  the  patient  had  pain  on  the 
ulcerated  surfaces.  The  subjacent  tissue  was  remarkably  indurated  and 
the  clitoris  red  and  swollen.     On  histological  examination  tuberculous 


126        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

lesions  with  bacilli  were  demonstrated.  Diagnosis,  tuberculosis  of  the 
clitoris  and  vestibule. 

Rechenbach.51  The  patient  had  dysmenorrhea  and  dyspareunia.  The 
heart  and  lungs  were  normal.  The  labia  minora  were  hypertrophied  and 
elephantoid.  A  small,  edematous  tumor  was  present  on  the  clitoris. 
In  front  of  the  urethral  orifice  was  an  ulcer,  the  size  of  a  five  franc  piece, 
covered  with  soft,  fungous,  easily  bleeding  granulations.  The  uterus 
was  small  and  anteflexed,  and  the  pelvic  organs  were  otherwise  normal. 
The  growth  was  excised.  Recovery.  On  histological  examination 
leukocytic  infiltration  and  giant  cells  were  observed  and  showed  the  usual 
microscopic  picture  of  tuberculosis. 

Boursier.52  Case  I.  Woman,  aged  sixty-three  years,  who  was  pale, 
thin,  and  cachetic  looking.  She  first  noticed  an  enlargement  of  the  right 
labium  majus  one  year  previous  to  examination.  This  gradually  in- 
creased in  size  and  finally  measured  15x12  cm.  and  5  or  6  cm.  in  thick- 
ness. The  skin  over  the  tumor  was  thickened,  hypertrophied,  and  pre- 
sented the  appearance  of  an  elephantiasis.  It  was  hard  and  elastic  in 
consistency.  A  diagnosis  of  elephantiasis  was  made.  The  tumor  was 
extirpated  and  the  wound  healed  by  first  intention.  Histological  exam- 
ination showed  the  lesion  to  be  tuberculous.  No  tubercle  bacilli  were 
sought  for.  A  year  later  a  similar  tumor  with  slight  superficial  excor- 
iations appeared  on  the  left  labium  majus.  A  little  later  the  woman  had 
an  attack  of  erysipelas.  This  was  followed  by  a  second  attack,  which 
was  complicated  by  pelvic  abscesses,  one  of  them  pointing  in  the  region 
of  the  anus,  the  other  in  the  vagina.  These  were  incised  and  the  anal 
and  perineal  regions  at  this  time  presented  an  elephantoid  appearance. 
Signs  of  tuberculosis  also  developed. 

The  inguinal  glands  were  palpable.  The  left  labium  minus  became 
hypertrophied  and  indurated.  The  vagina  was  normal.  The  cervix 
showed  fungoid  masses,  a  curetted  piece  of  which,  when  examined  micro- 
scopically, presented  evidence  of  tuberculosis.  The  tumor  subsequently 
became  ulcerated. 

Case  2.  Patient,  twenty  years  of  age.  The  case  was  one  of  simple 
hypertrophy,  the  vulva  being  enlarged  to  three  times  its  normal  size. 
The  left  labium  minus  was  hypertrophied  and  wrinkled.  The  region  of 
the  clitoris  and  both  labia  majora  were  also  thickened  and  edematous, 
but  no  ulcerations  were  present.  The  condition  resembled  an  elephan- 
tiasis. The  apex  of  the  right  lung  was  suggestive  of  tuberculosis.  The 
patient  had  pleurisy  three  years  ago.  The  tumors  were  excised  and  no 
recurrence  was  noted.  On  histological  examination  the  specimens  proved 
to  be  tuberculous.     The  pulmonary  lesions  progressed,  and  although  a 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  127 

fatal  termination  was  not  noted,  an  unfavorable  prognosis  was  given  on 
this  account. 

Case  3.  Patient,  aged  twenty-six  years,  had  pulmonary  tubercu- 
losis. She  had  ulceration  of  the  middle  part  of  the  free  border  of  the 
left  labium  minus,  which  was  excised.  Histological  examination  showed 
tuberculosis  with  giant  cells. 

Karajan.54  Primary  Tuberculosis  of  the  Vulva  with  Elephantiasis 
of  the  Clitoris.  Child,  2  years  of  age,  whose  hands  were  frequently 
on  the  genitals.  Family  history  negative.  There  had  been  a  swelling 
and  itching  of  the  genitalia  for  one  year.  No  fever,  cough,  or  diar- 
rhea or  signs  of  visceral  tuberculosis  were  present.  On  separation  of 
the  swollen  labia  majora,  a  penis  shaped  tumor  was  revealed,  which  meas- 
ured 3x1.5  cm.,  with  small  areas  of  loss  of  tissue  substance,  each  area 
about  the  size  of  a  pin's  head.  This  tumor  represented  the  clitoris,  the 
distal  extremity  of  which  was  covered  by  an  eczematous  prepuce.  The 
surrounding  skin  was  red,  excoriated,  and  covered  with  crusts.  Examina- 
tion and  voiding  of  urine  caused  pain.  The  inner  genitalia  were  normal. 
The  diagnosis  of  elephantiasis  of  the  clitoris  was  made.  The  tumor  was 
excised  and  ten  months  afterward  the  patient  returned,  her  father  stating 
that  the  wound  had  healed,  but  recently  a  new  ulcer  had  appeared.  At 
this  time  there  was  an  inguinal  adenitis.  Gradually  a  tumor,  one  centi- 
meter in  length,  developed  at  the  site  of  the  original  operation.  The  ulcer 
was  situated  on  the  right  side,  involving  the  vulva  and  vagina.  Histologi- 
cal examination  showed  both  tumors  to  be  composed  of  connective  tissue, 
partially  covered  by  normal  skin,  in  which  tubercles  were  irregularly  dis- 
tributed below  the  derma.  These  were  characteristic  of  tuberculosis. 
The  severe  pain  on  urination  persisted.  No  tubercle  bacilli  were  demon- 
strated in  the  discharge  from  the  tumor.  One  year  after  the  operation  an 
ulcer  was  present  on  the  wall  at  the  entrance  of  the  vagina. 

Jesionek.55  Woman,  75  years  old,  was  admitted  to  the  clinic  with  a 
diagnosis  of  carcinoma  vulvae.  She  had  previously  suffered  a  fracture 
of  the  neck  of  the  femur.  The  lungs  were  negative,  although  there  was 
a  tuberculous  family  history.  A  dark  red,  prominent  tumor,  with  an 
irregular  surface,  was  present  at  the  urethral  outlet,  which  bled  easily 
on  touch.  The  tumor  was  removed.  Microscopic  examination  of  the 
subepithelial  tissue  presented  accumulation  of  lymphoid  cells,  granu- 
lation tissue,  and  giant  cells.  The  author  believed  this  to  be  tubercu- 
losis. 

Demme.25  Case  1.  Woman,  64  years  of  age.  For  one  and  one  half 
years  she  had  hematuria,  which  gradually  became  associated  with  pain. 
There  were  polypoid  vegetations  of  the  urethra,  which,  when  excised 


128        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

and  examined  histologically,  showed  typical  giant  cells.  The  process 
was  localized  to  the  superficial  layers  of  the  mucosa. 

Case  2.  In  a  woman,  aged  33  years,  the  urethra  was  involved  by 
tuberculous,  polypoid  vegetations,  and  the  greater  and  lesser  labia  were 
the  seat  of  a  slight  elephantiasis,  without,  however,  specific  tuberculous 
findings  on  histological  examination. 

Case  3.  Woman,  23  years  of  age,  had  indolent  tumefaction  of  right 
labium  majus  with  ulceration.  A  right  sided  inguinal  adenitis  was  pres- 
ent. Abdominal  pain,  swelling,  meteorism,  diarrhea,  pallor  and  other 
evidence  of  intraperitoneal  involvement  became  manifest.  Finally  both 
labia  majora  were  involved.  The  introitus  vulvae  was  ulcerated  and 
the  inguinal  glands  enlarged  bilaterally.  The  vulva  probably  became 
infected  by  contact  with  the  intestinal  discharges. 

In  1851,  Geil 5  reported  three  cases  of  vaginal  tuberculosis  which 
accompanied  uterine  lesions.  These  three  cases  were  the  only  ones 
occurring  among  forty-five  cases  of  uterine  tuberculosis. 

Purslow  56  reports  a  case  of  tuberculous  elephantiasis  of  the  vulva 
in  a  woman  37  years  old.  Both  labia  were  affected,  swollen,  and  the 
surface  covered  with  small,  round  depressions  with  intervening  eleva- 
tions, and  more  or  less  coated  with  thin  serum.  The  surface  was  not 
reddened.  The  patient  also  suffered  from  what  was  clinically  diagnosed 
as  tuberculous  pelvic  peritonitis,  for  which  an  abdominal  section  was 
performed.  The  vulva  swelling  was  excised.  No  pulmonary  tuberculosis 
was  present.  Although  the  case  is  reported  as  one  of  tuberculous  ele- 
phantiasis of  the  vulva,  no  proof  is  brought  forward  to  show  that  this 
type  of  infection  was  present,  nor  was  syphilis  excluded.  A  doubtful 
case. 

Hartmann.57  Woman,  aged  27  years,  with  well  marked  family  his- 
tory of  tuberculosis.  She  had  tuberculous  hypertrophy  of  the  external 
urinary  meatus  and  stricture  of  the  urethra.  Had  pains  and  frequency 
of  micturition  for  six  years,  unimproved  by  various  treatments.  Exam- 
ination showed,  in  the  region  of  the  urethral  orifice,  a  gray  crater-like 
ulcer  with  expanded,  thickened  edges.  Two  cm.  within  the  urethra  a  well 
marked  stricture  was  found.  The  urethra  was  freed  as  far  as  the  upper 
limits  of  the  structure  and  excised.  The  operation  was  successful. 
Histologic  examination  showed  the  tissue  to  be  the  seat  of  a  well  marked 
tuberculosis.  The  urethral  walls  were  thickened,  especially  the  submu- 
cous coat,  and  in  this  situation  numerous  tubercles  were  present. 
Tubercle  bacilli  could  not  be  demonstrated,  but  animal  tests  were  positive 
for  tuberculosis. 

Davidsohn's  28  case  concerned  a  woman  who  had  an  excessively  hard 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  129 

labor.  Two  days  later  an  acute  miliary  tuberculosis  developed  and 
proved  fatal  in  three  weeks.  At  autopsy,  the  entire  vagina,  as  well  as 
the  labia  minora,  were  found  thickly  studded  with  recently  formed  miliary 
tubercles.  The  cervix  and  urinary  passages  were  not  involved.  The 
diagnosis  was  confirmed  by  both  histologic  and  bacteriologic  proof. 

Cayla.2  The  patient  died  of  an  extensive  pulmonary  tuberculosis. 
Autopsy  showed  that  the  vulva,  especially  the  labia  majora,  was  swollen, 
indurated,  and  the  seat  of  a  number  of  ulcers.  Nodules  were  also  pres- 
ent. The  ulcers  were  chiefly  in  the  internal  aspect  of  the  labia  majora. 
The  ulceration  also  involved  the  vagina  and  skin  perineum  as  far  as  the 
anus,  and  in  the  former  were  extensive.  A  few  vegetative  outgrowths 
were  present.  The  uterus  was  normal.  Histologic  verification  of  the 
diagnosis. 

Deuse  58  reports  three  cases  of  genital  tuberculosis  in  children. 

Case  1.  A  child  13  months  old.  The  ulcer  was  situated  upon  the 
inner  aspect  of  the  labium  minus.  In  the  discharge  from  the  ulcer  numer- 
ous tubercle  bacilli  were  found.  Death  occurred  when  sixteen  months 
of  age  from  tuberculous  meningitis,  at  which  time,  in  addition  to  the 
ulcer  of  the  vulva,  one  was  found  in  the  vagina.  This  also  contained 
tubercle  bacilli. 

Case  2.  A  child  7  months  of  age.  The  father  was  tuberculous.  The 
ulcer  was  situated  at  the  orifice  of  the  vagina. 

Case  3.  A  child  15  months  of  age,  with  a  good  family  history.  A 
mucopurulent  leukorrhea  appeared  after  an  attack  of  measles.  The  ulcer 
was  situated  at  the  orifice  of  the  vagina  and  its  tuberculous  nature  was 
proven  by  histologic  examination.  Tubercle  bacilli  were  also  demon- 
strated in  the  iliac  gland.    The  child  died  from  a  tuberculous  pneumonia. 

Stealy.59  Patient  had  a  family  history  of  tuberculosis.  Had  septi- 
cemia three  months  ago.  When  first  observed  the  temperature  was  990- 
ioo°  F.  Pulse  100-120.  The  patient  fell  astride  a  hard  object,  causing 
a  laceration  of  the  vestibule,  in  the  region  of  the  external  urinary  meatus. 
The  edges  were  undermined,  the  base  was  the  color  of  apple  jelly  and 
contained  about  ten  macroscopic  tubercles.  The  curettings  of  the  ulcer 
contained  tubercle  bacilli,  as  proven  by  staining  and  animal  inoculation. 
Following  the  anesthetic,  pulmonary  phthisis  developed.  The  lungs  were 
thought  to  have  been  normal  prior  to  the  operation. 

Daniel 60  describes  a  case  of  tuberculosis  of  the  vulva,  in  which  the 
labia  and  preputium  clitoridis  are  hypertrophied  and  the  inguinal  glands 
enlarged.  The  Wassermann  reaction  was  negative,  the  ophthalmic  re- 
action positive,  and  antiluetic  treatment  had  no  effect  on  the  disease. 
The  woman  was  36  years  of  age  and  had  had  three  miscarriages.    Daniel 


130        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

believes  that  the  disease  was  transmitted  from  the  husband  by  coitus  and 
that  the  disease  was  primary  in  the  vulva.  The  husband  had  syphilis 
and  a  tuberculous  lesion  at  the  apex  of  one  lung.  Extirpation  of  the 
diseased  parts  and  of  the  inguinal  glands  resulted  in  cure.  This  is  a 
case  of  non-ulcerating  tuberculosis  of  the  hypertrophic  variety.  The 
diagnosis  of  tuberculosis  was  verified  by  histologic  examination. 

Meriel  52  reports  two  cases  of  tuberculosis  of  the  vulva. 

Case  i.  This  was  of  the  hypertrophic  form,  a  tumor  which  arose 
from  the  labium  minus,  covered  the  vulva,  and  had  the  appearance  of 
elephantiasis.  The  neighborhood  of  the  clitoris,  the  posterior  commis- 
sure, and  the  labia  majora  was  thickened  and  condylomatous.  The 
mucosa  was  not  thickened,  nor  were  there  any  ulcerations.  At  the  apex 
of  the  right  lung  tuberculosis  seemed  to  be  threatened.  The  hyper- 
trophic portions  of  vulva  were  excised  and,  upon  microscopic  examina- 
tion, proved  to  be  tuberculous.  Several  years  later  no  local  recurrence 
had  occurred  although  the  lung  condition  had  advanced. 

Case  2.  The  second  case  was  the  more  common  ulcerative  form  of 
vulvar  tuberculosis  and  in  it  also  the  lungs  were  involved.  Meriel 
believes  that  the  disease  may  be  propagated,  not  only  through  the  circula- 
tion, but  also  by  direct  infection. 

Kromer  61  in  reporting  some  rare  cases  of  tuberculosis  of  the  female 
genitalia,  briefly  mentions  two  cases,  one  of  elephantiasis  of  the  vulva, 
which  had  its  origin  from  a  tuberculous  skin  lesion,  and  the  other  an 
ulcerative  lesion  at  the  mucocutaneous  junction. 

Zweigbaum.62  The  case  was  one  of  secondary  infection  from  the 
vagina.  The  patient  died  of  pulmonary  tuberculosis  and  at  autopsy  the 
uterus,  tubes  and  ovaries  were  found  normal.  The  vagina  and  external 
genitalia  were  the  seat  of  ulcerative  lesions  which  upon  histologic  exam- 
ination presented  the  characteristic  picture  of  tuberculosis. 

Author's  case.  Ulcerative  tuberculosis  of  the  external  genitalia, 
secondary  to  hip  joint  disease.  Patient,  aged  22  years,  and  single.  For 
seven  years  she  had  been  a  sufferer  from  a  slow,  progressive,  tuberculous 
hip  joint  disease,  which  neither  operation  nor  careful  general  treatment 
seemed  to  affect.  When  seen  by  the  author,  both  labia  ma  jus  and  minus 
were  swollen  and  edematous.  This  conditioif  was  most  marked  on  the 
left,  where  the  lesser  labium  was  enlarged  to  six  times  its  normal  size. 
It  was  slightly  reddened  and  a  few  engorged  vessels  were  present  on  its 
surface.  The  enlargement  on  both  sides  was  apparently  due,  not  so 
much  to  an  hypertrophy  or  inflammation,  as  to  an  edema.  On  the  outer 
surface  of  the  labium  minus  and  the  inner  and  adjacent  surface  of  the 
labium  majus  on  the  left  side  was  a  fairly  deep  ulceration  about  8x4x1.5 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  131 

cm.  The  base  was  grayish  and  covered  with  a  thick,  tenacious,  purulent 
discharge.  The  edges  near  the  deepest  portion  of  the  ulcer  were  ragged 
and  undermined,  while  in  the  shallow  portion  of  the  ulcer  they  were 
fairly  smooth.  The  edges  and  base  of  the  lesion  were  hard,  and  the 
former  more  or  less  elevated.  The  ulcer  was  essentially  chronic  in 
appearance  and  even  viewed  alone  did  not  particularly  suggest  either  a 
malignant  or  venereal  origin.  The  labium  minus  was  chiefly  affected, 
and  the  lesion  on  the  majus  was  probably  the  result  of  either  an  extension 
by  continuity  or  a  contact  infection,  which  was  impossible  to  determine 
owing  to  the  advanced  stage.  Two  smaller  but  similar  ulcers  were 
present  on  the  skin  perineum,  one  near  its  center  and  the  other  closely 
approaching  the  anus.  The  entire  skin,  perineum,  and  adjacent  surface 
was  the  seat  of  a  dermatitis.  The  vagina,  uterus,  and  appendages  were 
normal.  The  left  hip  joint  was  the  seat  of  an  extensive  tuberculosis, 
and  the  entire  skin,  perineum,  and  adjacent  region  were  honeycombed 
with  sinuses  which  were  discharging  profusely.  None  of  these  sinuses 
actually  involved,  by  continuity,  the  genital  lesion  above  mentioned.  A 
small  piece  of  the  ulcer  of  the  labia  was  excised,  and  histologic  examina- 
tion showed  the  typical  picture  of  tuberculosis,  numerous  giant  cells  and 
tubercles  being  present.  A  few  tubercle  bacilli  were  also  demonstrated. 
In  this  case  the  genital  condition  was  clearly  secondary  to  the  hip  joint 
disease,  which  had  antedated  it  for  over  six  and  a  half  years,  and  probably 
had  resulted  from  the  constant  drenching  of  the  skin  surface  with 
tubercle  bacilli  bearing  discharges.  The  patient  was  referred  to  a 
general  surgeon  and  died  nine  months  later,  up  to  which  time  the  ulcer 
on  the  external  genitalia  and  adjacent  structure  had  enlarged  but  little. 

Winckel.1  Case  1.  The  patient  was  28  years  of  age  and  gave  a  nega- 
tive family  and  previous  history  of  tuberculosis.  Springing  from  the 
labium  minus  was  a  firm,  reddish,  rounded,  tumor-like  outgrowth  the  size 
of  a  pigeon's  egg.  On  the  inner  aspect  of  the  mass  was  a  superficial' 
granular  ulcer  1  cm.  in  diameter.  The  labium  majus  and  clitoris  were 
enlarged,  as  well  as  opposite  labium  majus.  Considerable  edema  was 
present.  The  tumor  was  excised  and  the  diagnosis  verified  by  histologic 
examination. 

Case  2.  The  patient  was  26  years  of  age  and  gave  a  negative  pre- 
vious history  of  tuberculosis.  The  region  of  the  vulva  was  hardened, 
swollen,  and  the  base  edematous,  the  labia  minora  and  clitoris  were 
also  indurated.  Between  the  labia  was  an  ulcer  which  discharged  puru- 
lent material.     The  diagnosis  was  verified  by  histologic  examination. 

Poverlein.36  The  patient  was  a  multipara,  married  and  49  years  of 
age.    The  family  history  was  negative  for  tuberculosis.    Trauma  appears 


132        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

to  have  been  a  predisposing  factor  in  the  production  of  the  genital  lesion. 
The  genital  lesion  had  been  present  for  a  long  time  and  growing  slowly. 
There  was  dysuria  and  pain  on  defecation.  From  its  size  the  lesion  also 
caused  discomfort.  When  examined,  a  number  of  tumor-like  masses 
were  found  which  practically  obliterated  the  vulvar  orifice.  These  sprang 
from  the  right  labia  ma  jus  and  minus.  The  tumor-like  masses  were 
wart-like  in  appearance,  wrinkled,  pigmented,  and  the  outer  surface  was 
covered  with  coarse  hair.  A  diagnosis  of  sarcoma  of  the  labia  majus 
and  minus  was  made.  Excision  was  performed  and  the  correct  char- 
acter of  the  lesion  determined  by  histologic  examination. 

Hamburger.63  A  child  3  years  of  age  presented  an  ulcer  on  the  inner 
surface  of  the  labium  minus.  The  ulcer  was  irregular  in  outline,  the 
edges  were  rough  and  the  surface  covered  with  purulent  discharge. 
Tubercle  bacilli  were  demonstrated  in  the  lesion.  Hamburger  believes 
the  case  a  primary  one. 

Bender.13  The  patient  was  39  years  of  age.  Both  labia  minora  were 
transformed  into  tumor-like  masses  two  or  three  centimeters  in  diameter. 
The  labia  majora  were  also  involved.  The  surface  of  the  lesions  was 
irregular,  wrinkled  and  like  the  skin  of  an  orange,  and  was  reddish 
purple  in  color.  On  the  superior  aspect  of  the  right  labium  minus  was 
a  small  dark  colored  nodule.  The  clitoris  and  surrounding  skin  were 
swollen  and  indurated.  An  excision  was  performed  and  the  diagnosis 
verified  by  histologic  examination. 

Logothetopulos.64  A  woman  of  advanced  age  presented  herself,  suf- 
fering from  symptoms  which  had  led  to  the  diagnosis  of  cancer  of  the 
vulva.  The  menopause  had  been  established  for  some  time.  Examina- 
tion showed  a  fairly  large  reddish  tumor,  the  surface  of  which  was 
roughened  and  irregular.  It  was  painful  when  pressed  upon  and  bled 
easily  when  slightly  traumatized.  The  uterus  and  adnexa  were  normal. 
The  tumor  was  excised  and  the  diagnosis  verified  by  histologic  examina- 
tion. The  patient  died  six  months  after  the  operation  and  autopsy 
showed  tuberculosis  of  the  right  lung. 

Legane.32  The  patient  was  a  child  who  suffered  from  tuberculosis 
of  the  kidney  and  secondary  involvement  of  the  bladder.  The  vulva 
and  region  of  the  hymen  were  the  seat  of  an  irregular  ulcer,  which 
caused  pain  on  movement  and  following  urination.  Considerable  dis- 
charge was  present.  Legane  mentions  the  possibility  of  this  being  an 
implantation  lesion  from  tubercle  bacilli  in  the  urine,  as  the  kidney  lesion 
had  antedated  the  ulcer  on  the  genitalia.  Histologic  verification  of  the 
diagnosis. 

Forgue    and    Massabeau.65      Secondary    hypertrophic    tuberculosis 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  133 

of  the  vulva.  The  patient  was  a  woman  25  years  of  age,  who,  fif- 
teen years  prior  to  the  onset  of  the  genital  symptoms,  had  had  a  tuber- 
culous adenitis.  This  had  been  cured  by  surgical  measures.  Examina- 
tion showed  pulmonary  tuberculosis.  For  some  time  there  had  been 
profuse  purulent,  and  at  times  blood  streaked  leukorrhea.  A  year  or 
more  ago  an  enlargement  of  the  middle  of  the  right  labium  majus  was 
noticed.  This  continued  to  grow  and,  when  observed,  was  of  the  size 
and  somewhat  the  shape  of  an  adult  scrotum,  it  was  fairly  firm  to  the 
touch,  partially  covered  with  hair,  the  skin  was  somewhat  wrinkled  and 
discolored,  the  base  and  opposite  labium  were  distinctly  edematous. 
Springing  from  the  lower  side  of  the  elephantiasis-like  mass,  and  tend- 
ing to  become  pedunculated,  was  a  polypoid  or  vegetation-like  tumor; 
this  was  markedly  papillary  in  character,  and  was  the  size  of  a  small  nut. 
The  skin  on  the  inner  surface  of  both  labia  majora  was  moistened  and 
somewhat  macerated.  The  inguinal  glands  were  enlarged  and  suppurat- 
ing. There  was  edema  of  the  right  leg.  Excision  of  the  diseased  area 
and  of  the  enlarged  glands  was  performed  and  the  diagnosis  verified  by 
histologic  examination.  Nine  months  later  the  patient  returned  to  the 
hospital.  There  was  marked  tumefaction  at  the  site  of  former  opera- 
tion and  the  opposite  labium  was  also  affected.  The  right  leg  was  ex- 
tremely edematous.  The  patient  died  in  a  short  time  from  pulmonary 
tuberculosis.    Autopsy. 

Brault.33  The  patient  was  a  child  7  years  of  age,  in  whom  pulmonary 
tuberculosis  was  present.  There  were  fever  and  albumen.  About  one 
year  previously  an  ulcer  had  appeared  upon  the  labia  minora  and  clitoris. 
This  spread  rather  rapidly  and,  when  seen,  occupied  both  labia  majora 
and  minora,  the  clitoris,  and  extended  backwards  over  the  perineum 
half  way  to  the  anus  and  inwards  into  the  vagina.  The  ulcer  was  dark 
reddish  in  color  and  soft  and  friable  to  the  touch.  Here  and  there  yel- 
lowish areas  were  present.  The  inguinal  glands  were  enlarged.  Peri- 
tonitis developed,  from  which  the  patient  died.  Autopsy  and  histologic 
and  inoculation  verification  of  the  diagnosis  was  obtained. 

Kromer.66  A  large  ulceration  was  present  in  the  vulvar  region,  the 
clitoris  had  been  destroyed,  and  there  was  involvement  of  the  external 
urinary  meatus  and  labia  minora.  The  ulcer  possessed  an  irregular 
outline,  somewhat  undermined  and  swollen  edges,  and  a  granular  base, 
more  or  less  covered  with  thick  purulent  discharge.  Biopsy  was  per- 
formed and  revealed  the  true  character  of  the  lesion.  Radiotherapy 
produced  some  amelioration  of  the  condition.  Finally,  however,  the  dis- 
eased area  was  excised.    Recovery. 

Schuchardt.67    The  patient  was  a  girl  who  for  some  time  had  had  a 


134        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

cough.  Loss  of  weight,  night  sweats,  and  other  signs  of  pulmonary 
tuberculosis  were  present.  A  physical  examination  showed  the  usual 
evidences  of  phthisis.  Tubercle  bacilli  were  also  recovered  from  the 
sputum.  Some  time  previously,  a  small  ulcer  had  appeared  on  the  lower 
portion  of  the  labium  majus.  This  had  enlarged  slowly  but  progressively 
and  another  ulcer  formed  at  the  introitus.  These  were  chronic  looking 
shallow  ulcers,  with  slightly  elevated  and  indurated  edges.  A  moderate 
amount  of  discharge  was  present.  Excision  and  histologic  verification 
of  the  diagnosis. 

Clark68  mentions  two  cases  of  tuberculosis  of  the  vulva,  both  of 
which  were  secondary.     No  detailed  report  is  given. 

Kelly.50  The  patient  was  a  widow  35  years  of  age.  A  small  ulcer 
appeared  in  the  region  of  the  clitoris  one  year  before  patient  came  under 
observation.  Ulcer  increased  in  size  gradually.  It  presented  a  reddened, 
eaten  out  appearance.  The  chief  symptom  was  a  stinging  pain  at  urina- 
tion. Ulcer  was  excised  and  tubercle  bacilli  demonstrated  in  small  num- 
bers in  the  specimen. 

Bulkley.3  Patient  aged  42.  One  child  and  one  miscarriage.  Lesion 
appeared  as  small  raw  area  on  inner  surface  of  labia  minora  and  pro- 
gressed for  five  years.  Dyspareunia  and  occasional  burning  pain  the 
only  subjective  symptoms.  No  evidence  of  primary  focus  of  tubercu- 
losis other  than  that  in  the  genital  tract.  When  observed  left  labium 
was  the  seat  of  a  dumbbell  shaped,  partially  undermined  ulcer.  No 
hypertrophy  and  but  little  induration.  Base  of  ulcer  was  grayish  and 
did  not  bleed  easily,  but  was  more  or  less  covered  by  mucus  and  pus. 
Excision.  One  month  later  small  recurrence  in  form  of  an  ulcer.  This 
was  treated  locally,  and  four  months  from  original  operation  was  cau- 
terized with  the  Paquelin  cautery.  Diagnosis  confirmed  by  histologic 
examination.  No  tubercle  bacilli  demonstrated.  Death  six  months  after 
operation  with  signs  of  acute  miliary  tuberculosis. 

MacDonald.69  Case  1.  A  multipara  aged  40.  No  other  tuberculosis 
focus  described.  Death  after  two  and  one  half  years.  At  time  of  death 
there  was  a  lupus-like  lesion  involving  entire  vulva  and  perineum.  The 
surface  was  ulcerative. 

Case  2.  A  primipara  gave  a  history  of  a  fall  upon  the  vulva  two 
years  prior.  The  lesion  was  hypertrophic  and  ulcerative.  One  year 
after  curettage  and  cauterization  there  was  no  return. 

Defontaine.70  The  patient,  aged  40,  gave  a  history  of  pulmonary 
tuberculosis.  A  lesion  of  the  wrist  and  a  rectovaginal  fistula  were  also 
present.  The  labium  majus  was  the  seat  of  a  tuberculous  fistula,  which 
was  cauterized  and  healed  in  six  months. 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  135 

Weinlechner.71  A  multipara  38  years  of  age.  No  other  tuberculous 
focus.  Occupying  the  labia  on  each  side  was  a  large  ulcer,  which  was 
treated  by  cauterization.  Recurrence  in  one  and  one  half  years.  The 
tuberculous  ulcer  developed  upon  a  syphilitic  lesion. 

Haberlin.72  A  tripara  27  years  of  age.  No  other*  focus  of  tubercu- 
losis reported.  The  entire  introitus,  including  both  labia  majus  and 
minus,  clitoris  and  adjacent  parts,  was  the  seat  of  a  hypertrophic  ulcer. 
Treated  by  excision.     Result  not  stated. 

Hintze.73  A  tripara  presented  a  large  tuberculous  ulcer  involving 
the  mons,  both  labia,  and  the  perineum.  This  was  excised.  Result  not 
stated.    No  other  tuberculous  focus  found.    Possibly  a  primary  case. 

Brosin.74  The  specimen  was  a  pathologic  one  and  but  few  data  given. 
The  patient  was  an  aged  woman.  There  was  a  tuberculous  ulcer  on  the 
vulva. 

Fiocco  and  Levi.75  A  hypertrophic  ulcer  involving  the  vulva  was 
treated  by  curettage  and  cauterization.  Rapid  healing.  End  result  not 
stated.    Probably  a  secondary  case. 

Hansen.76  This  was  an  autopsy  case  of  a  child  4  years  of  age,  who 
died  of  a  general  tuberculosis.  It  is  thought  by  Hansen  that  the  infec- 
tion had  been  primarily  renal.  The  vulva  was  the  seat  of  a  miliary 
tuberculosis.    The  tubes,  uterus  and  vagina  were  also  involved. 

Erhmann.77  Case  1.  The  patient  was  a  prostitute,  32  years  of  age, 
suffering  from  pulmonary  tuberculosis.  Surrounding  the  external  uri- 
nary meatus  was  a  tuberculous  ulcer.  This  was  treated  with  iodoform 
and  healed  in  six  months. 

Case  2.  The  patient  was  50  years  of  age  and  had  a  tuberculous  ulcer 
on  the  labium  majus  and  posterior  commissure.  This  was  treated  as  in 
Case  1.    Result  not  stated. 

Case  3.  A  patient,  56  years  of  age,  who  presented  no  signs  of  pul- 
monary tuberculosis,  suffered  from  a  hypertrophic  ulceration  involving 
the  labium  majus  and  fourchette.     This  was  excised.     Result  not  stated. 

DePaoli.78  Case  1.  The  patient  had  a  tuberculous  hypertrophic  ul- 
ceration involving  both  labia. 

Case  2.  This  was  a  similar  lesion  involving  similar  parts.  In  this 
patient  the  genital  lesion  was  secondary  to  a  tuberculous  peritonitis. 

Chiarabba.79  This  patient  had  a  hypertrophic  ulceration  involving 
the  labia  majus  and  minus,  evidently  secondary  to  a  tuberculosis  of  the 
peritoneum,  fallopian  tubes,  uterus,  and  cervix. 

Audry  and  Combleran.80  Patient,  aged  26,  had  a  tuberculous  ulcera- 
tive lesion  involving  the  right  labium  minus.  Tuberculous  inguinal 
adenitis  was  also  present.    The  ulcer  was  treated  by  excision. 


136        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Frattali.sl  The  patient  was  19  years  of  age  and  had  a  tuberculous 
ulcer  involving  the  labia  majora  and  vagina.  Tuberculous  inguinal 
adenitis  was  also  present. 

Daniel  and  Jianu.82  Case  1.  A  multipara,  aged  45  years,  presented 
an  hypertrophic  ulceration  of  both  labia  minora  and  clitoris.  This  was 
treated  by  excision  and  healed.  The  final  result  not  stated.  This  patient 
also  suffered  from  tuberculosis  of  the  rectum. 

Case  2.  The  patient,  aged  45  years,  and  who  exhibited  no  evidence  of 
tuberculosis  elsewhere  in  the  body,  showed  a  hypertrophic  ulceration  of 
the  labia  majora,  which  was  treated  by  excision.     End  result  not  stated. 

Kromer.83  A  quintipara  presented  herself,  suffering  from  a  tubercu- 
lous hypertrophic  ulceration  of  the  vulva.  This  was  treated  by  excision. 
End  result  not  stated.  • 

Mauler.84  Case  1.  An  autopsy  case.  Subject  aged  37.  Postmortem 
showed  tuberculosis  of  lungs,  intestines,  spine,  uterus,  tubes,  and  vagina. 
The  introitus  was  the  seat  of  multiple  ulcers. 

Case  2.  Autopsy  case.  Age  41.  Postmortem  showed  tuberculosis 
of  lungs,  joints,  kidney,  suprarenal,  spine,  fallopian  tubes,  uterus,  and 
vagina.    Ulcers  were  also  present  in  the  introitus. 

Stockel.85  A  patient,  28  years  of  age,  suffered  from  an  ulcer  on  the 
anterior  commissure.  This  was  treated  by  excision  and  cauterization. 
Recovery.  End  result  not  stated.  Miliary  tuberculosis  of  the  intestines 
was  present. 

Rossle.86  Autopsy  case.  This  was  a  subject  87  years  of  age.  Tuber- 
culosis of  the  lungs,  uterus,  cervix  was  present.  In  the  anterior  com- 
missure was  a  tuberculous  ulcer. 

Wichmann  87  reports  a  case  of  extensive  ulcerative  tuberculous  lesion 
involving  the  urethra,  clitoris,  and  vulva  in  a  woman  37  years  of  age. 
The  case  was  probably  a  secondary  infection  and  was  combined  with 
syphilis. 

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40  474. 

38.  Bloodgood,  J.  C.    Jr.  Am.  Med.  Assoc.     1913.    61 1911. 

39.  Veit,  J.     Monschr.  f.  Gebh.  u.  Gyn.   Oct.,  1902. 

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42.  Lecene,  P.    Ann.  de  Gyn.  et  d'obst.    1909.   6,  77. 

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44.  Wolff,  B.     Deutsch.  Med.  Woch.    1907.    33:780. 

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63.  Hamburger.    Wien.  Med.  Woch.    Feb.  3,  1906. 

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66.  Kromer,  M.    Rev.  de  gyn.  et  de  chir.  abd.    19 14.  22  139. 

67.  Schuchardt.    Arch.  f.  Klin.  Chir.    1892.  44:448. 

68.  Clark,  S.  M.  D.    New  Orl.  Med.  Surg.  Jr.   1908.   61  :i5. 

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70.  DeFontaine.    Quoted  by  Deschamps,  No.  17. 

71.  Weinlechner.     Sitzber.  d.  Gebh-Gyn.  Ges.  zu  Wien.    1889.   2  :g. 


TUBERCULOSIS  OF  THE  EXTERNAL  GENITALIA  139 

72.  Haberlin.    Arch.  f.  Gyn.    1890.   37:16. 

73.  Hintze.     Centrbl.  f.  Gyn.    1896.    20:1194. 

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yy.  Erhmann.    Wien.  Med.  Presse.     1901.     32:202. 

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ADDITIONAL  BIBLIOGRAPHY 

Labadia,   Lagrave,   et   Leguen.      Traite   medico-chirurgical   de 

gynecologic    2nd  edition,  p.  554. 
Veit,  J.    Handbuch  der  Gynakologie.   3  :i77. 
Delaunay  et  Darre.    Gaz.  des  Hop.    1904.    66  1657 ;  also  69 :685. 
Bender  et  Daniel.  Bui.  et  mem.  de  la  Soc.  Anat.  de  Paris.   1904. 

p.  56. 
Vladimiroff.     Ulcerative  Tuberculosis  of  the  urethra.     Khirurg. 

Arkh.  Vel.    1912.   26:562. 
Routier.     Rev.  Int.  de  la  tuberc.    1910.    18:30. 
Olow,  J.    Arch.  Mems.  d'obst.  et  de  gyn.    1916.    5:224. 
Camelot.     Sc.  med.  de  Lille.    19 10.    1  ^59.     (Deals  chiefly  with 

tuberculosis  of  the  male  genitalia.) 
Cozolari,  M.    Arch,  di  ost.  e  gin.     1908.    2:1. 
Brault.     Bui.  Soc.  Fr.  de  derm,  et  syph.    1912.    23:215. 
Abadie.     Bui.  Soc.  chir.  de  Paris.    1911.   37:1258. 
Darre,  H.,  et  Delaunay,  P.     Gaz.  des  Hop.     1904.     66:657. 

(This  paper  deals  chiefly  with  the  diagnosis  of  tuberculosis  of 

the  external  genitalia. ) 
Bonnin,  Mlle.  M.    These  de  Paris.   1904. 


CHAPTER  VII 

TUBERCULOSIS  OF  THE  VAGINA 

First  authentic  case  of  vaginal  tuberculosis  recorded — Anatomic  relationship  existing 
between  external  genitalia  and  vagina — Histologic  similarity — Etiology — Varieties 
— Symptoms — Experimentation  tending  to  show  that  trauma  and  irritation  are 
important  predisposing  factors  in  implantation  form — Ulcerative  appearance — 
Miliary  form — Hypertrophic — Characteristics — Syphilis,  malignant  neoplasms, 
chancroid,  gonorrhea,  noma  and  diphtheria  differentiated — Cases  cited — Primary 
tuberculosis  of  vagina  and  vulva — Histologic  examination — Cases  collected  by 
Chaton  and  others. 

In  1831  Raynaud1  described  a  case  of  vaginal  tuberculosis  which 
was  secondary  to  a  similar  infection  of  the  uterus  and  tubes.  In  1883 
Babes  2  reported  the  history  of  a  case  of  a  tuberculous  ulcer  in  the  rectum, 
which  had  perforated  into  the  vagina  and  resulted  in  a  tuberculous  vagini- 
tis, in  the  discharge  from  which  tubercle  bacilli  were  demonstrated.  This 
is  the  first  authentic  case  of  vaginal  tuberculosis  recorded. 

Owing  to  the  close  anatomic  relationship  which  exists  between  the 
external  genitalia  and  vagina  and  the  histologic  similarity  of  these  two 
areas,  tuberculosis  of  the  vagina  in  many  respects  resembles  that  of  the 
external  genitalia.  Indeed,  not  infrequently  vulvovaginal  lesions  are 
observed,  the  condition  in  these  cases  usually  originating  in  the  vagina, 
and  from  thence  spreading  by  direct  extension  to  the  external  genitalia, 
although  occasionally  the  converse  is  true. 

With  the  exception  of  lesions  of  the  external  genitalia,  infection  of 
the  vagina  is  the  rarest  variety  of  gynecologic  tuberculosis.  Among 
6,557  gynecological  specimens  in  the  gynecological  laboratory  of  path- 
ology at  the  University  of  Pennsylvania,  but  one  example  of  this  form 
of  infection  has  been  observed. 

Etiology. — Tuberculosis  of  the  vagina  may  be  primary  or  secondary, 
the  latter  being  by  far  the  most  frequent.  Direct  implantation  may  re- 
sult by  means  of  infected  semen,  sputum,  douche  nozzles,  fingers,  tubercle 
bacilli  bearing  discharges  from  the  upper  genital  tract,  or  from  without. 
Direct  implantation  may  therefore  be  either  an  autogenous  or  exogenous 
infection. 

The  secondary  variety  may  result  from  an  extension  from  nearby 
structures,  such  as  the  cervix,  external  genitalia,  or  intestine,  and  lastly 

140 


TUBERCULOSIS  OF  THE  VAGINA  141 

a  hematogenous  or  lymphogenic  infection  may  occur.  Weigert  20  has 
described  a  case  of  vaginal  tuberculosis  secondary  to  a  tuberculous  peri- 
tonitis, in  which  the  upper  genital  tract  was  normal.  Oppenheim,4  in 
seven  cases  of  tuberculous  vaginitis,  found  the  adnexa  involved  in  all, 
and  the  uterus  was  diseased  in  three. 

Tuberculosis  of  the  vagina,  resulting  from  a  direct  extension  by 
continuity,  is  relatively  frequent.  Daurios  5  observed  24  cases  of  recto- 
vaginal or  vesicovaginal  fistula  among  166  cases  of  genital  tuberculosis. 
Among  cases  of  cervical  tuberculosis,  the  abstracted  histories  of  which 
can  be  found  in  the  subsequent  chapter,  many  cases  of  extensions  to  the 
vagina  have  occurred.  Implantation  lesions,  caused  by  tubercle  bacilli 
bearing  discharges  from  the  upper  genital  or  urinary  tract,  are  by  no 
means  uncommon,  while  hematogenic  and  lymphogenic,  especially  in  the 
miliary  variety,  frequently  occur.  Pozzi 6  states  that  when  a  patient,  in 
advanced  phthisis,  develops  vaginal  lesions,  these  are  not  infrequently 
caused  by  contamination  with  tubercle  bacilli  bearing  diarrheal  dis- 
charges. 

Symptoms. — In  many  respects,  these  are  similar  to  those  produced 
by  lesions  of  the  external  genitalia.  As  the  disease  is  usually  secondary, 
the  symptoms  produced  by  the  primary  focus  are  often  the  most  pro- 
nounced, these  naturally  varying  widely.  The  symptoms  arising  from 
the  vaginal,  condition  present  nothing  pathognomonic.  Animal  experi- 
mentation tends  to  show  that  trauma  and  irritation  are  important  pre- 
disposing factors  in  the  implantation  form,  whether  it  be  of  the  auto- 
genous or  exogenous  variety.  In  guinea  pigs  and  rabbits  it  has  been 
found  almost  impossible  to  produce  vaginal  lesions  even  by  the  injec- 
tion of  large  quantities  of  a  pure  culture  of  tubercle  bacilli  into  the  vagina, 
unless  the  latter  has  been  previously  traumatized  or  a  preexisting  inflam- 
mation has  been  present.  Trauma  is  also  a  predisposing  agent  in  the 
hematogenic  or  lymphogenic  infection.  Apart  from  the  trauma,  the 
puerperium,  by  prolonged  maceration  of  the  vagina  mucosa  by  the 
lochia  and  the  hyperemia  which  exists  at  this  time,  appears  also  to  act 
as  a  predisposing  factor.  No  period  of  life  is  immune.  The  average 
age  of  twelve  cases  of  vaginal  tuberculosis  was  16.8  years,  the  extremes 
being  four  and  a  half  (Schrenk  7),  7,  13  and  15  months  (Demme  8)  and 
39  and  50  years  (Demme8). 

The  most  constant  symptom  is  discharge.  This  varies  in  character 
and  amount,  according  to  the  stage  and  variety  of  the  lesion.  In  the 
ulcerative  variety  it  may  be  blood  streaked,  and  this  is  especially  likely 
to  be  the  case  following  trauma.  It  is  usually  more  or  less  purulent. 
In  the  miliary  variety  it  is  generally  moderately  profuse,  thin  and  irri- 


142        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

taring.  There  is  often  little  discharge  in  the  hypertrophic  variety  and 
that  which  is  present  is  moderately  thin.  As  a  result  of  the  leukorrhea 
a  vulvovaginal  pruritus  is  frequent  and  may  be  the  most  severe  symptom. 
This  is  generally  the  result  of  the  toxins  in  the  discharge  and  is  most 
frequently  observed  in  children  in  whom  the  skin  is  thin  and  tender,  in 
women  of  unclean  habits,  and  in  neglected  cases.  Pain  is  rarely  a 
marked  feature,  as  one  of  the  characteristics  of  vaginal  and  vulvar 
tuberculosis  is  its  chronicity.  Dyspareunia  is  usually  present  and  dysuria 
is  not  infrequent.  Inguinal  adenitis,  especially  in  the  ulcerative  variety, 
and  in  the  late  stages  of  the  disease,  is  common.  It  is  most  likely  to  be 
present  when  the  lesions  are  in  the  outer  portions  of  the  vagina.  Fever 
and  other  systemic  disturbances  are  rarely  produced  by  the  vaginal 
lesions  alone,  but  are  often  present  as  a  result  of  tuberculosis  in  other 
parts  of  the  body. 

Varieties. — Tuberculosis  of  the  vagina  may  be  ulcerative,  hyper- 
trophic, or  miliary,  or  combinations  of  these  forms  may  occur.  As  in 
tuberculosis  of  the  external  genitalia,  the  ulcerative  variety  is  the  most 
frequent.  In  twelve  cases,  the  reports  of  which  have  been  sufficiently 
clear  to  determine  the  variety,  nine  were  of  the  ulcerative  variety,  two 
of  the  miliary,  and  one  of  the  hypertrophic. 

Ulcerative. — This  usually  begins  with  a  more  or  less  localized 
swelling,  which  softens  and  finally  breaks  down.  The  ulcers  may  be 
single  or  multiple,  the  latter  being  the  most  frequent.  The  ulcers  vary 
widely  in  size  and  frequently  coalesce.  Contact  lesions  are  not  infre- 
quent. In  the  base  of  the  ulcers  and  on  the  surface  of  the  adjacent 
vaginal  lining,  tubercles  can  often  be  seen.  Occasionally  vaginal  ulcers 
perforate  into  the  bladder  or  rectum  and  in  this  manner  produce  fistulas. 
Generally  the  converse  is  true,  the  lesion  having  its  origin  in  the  adja- 
cent hollow  viscus  and  from  here  penetrating  to  the  vagina. 

Miliary. — The  vaginal  lining  is  thickened,  reddened  and  more  or 
less  bathed  in  discharge.  A  varying  number  of  small  elevations,  usually 
grayish  or  yellowish  in  color  and  sometimes  partially  translucent,  are 
present.  Occasionally  one  of  these  tubercles  breaks  down  and  a  small 
ulcer  results.  Tubercles  in  varying  stages  of  development  are  usually 
present. 

Hypertrophic. — This  variety  is  nearly  always  secondary  and  usu- 
ally the  result  of  a  hematogenic  or  lymphogenic  infection.  It  is  charac- 
terized by  the  formation  of  one  or  more  tumor-like  masses.  The  masses 
are  usually  condyloma-like  in  appearance  and  resemble  similar  lesions 
occurring  on  the  external  genitalia,  except  that,  owing  to  the  local  condi- 
tions, such  as  pressure,  moisture,  etc.,  they  are  likely  to  be  somewhat 


TUBERCULOSIS  OF  THE  VAGINA  143 

modified.  These  are  frequently  discolored,  the  vaginal  lining  membrane 
about  their  base  is  thickened  and  reddened,  while  on  the  prominence 
of  the  tumor  the  covering  is  usually  thinned  or  may  be  absent.  Not  in- 
frequently these  masses  will  soften  and  break  down,  leaving  a  more  or 
less  deep,  ragged  ulcer.     A  generalized  vaginitis  is  often  present. 

The  chief  characteristic  of  all  these  varieties  is  their  appearance  of 
chronicity.  As  a  rule,  the  ulcers  do  not  bleed  easily  and  are  not  markedly 
tender. 

The  fornices  and  the  upper  third  of  the  posterior  vaginal  wall  are  the 
parts  of  the  vagina  most  frequently  attacked.  The  frequency  of  the  lat- 
ter location  can  be  accounted  for  by  the  fact  that  this  is  the  area  that 
receives  the  uterine  discharges.  The  upper  part  of  the  vagina  is  also 
more  prone  to  vaginal  lesions,  owing  to  the  frequent  direct  extension 
from  cervical  tuberculosis. 

Diagnosis. — Only  by  a  histologic  or  bacteriologic  examination  can 
a  positive  diagnosis  be  made.  Tubercle  bacilli  can  occasionally  be  dem- 
onstrated in  the  discharge,  especially  during  the  acute  stage.  However, 
the  presence  of  tubercle  bacilli  in  the  discharge  does  not  prove  that  there 
is  a  tuberculosis  of  the  vagina,  as  the  microorganism  may  have  been  swept 
down  from  the  lesion  in  the  upper  genital  tract.  In  order  to  determine 
this  point,  Schultze's  method  may  be  employed.  This  consists  in  thor- 
oughly cleaning  the  vagina  and  external  genitalia  and  then  inserting  a 
tight  fitting  occlusive  tampon  of  sterile  absorbent  cotton  against  the 
cervix.  If  the  secretion  that  collects  in  the  vagina  below  the  tampon 
contains  tubercle  bacilli,  this  is  evidence  that  a  vaginal  lesion  is  present, 
whereas,  if  the  upper  surface  of  the  tampon  is  alone  contaminated,  it  is 
evident  that  the  infection  is  confined  to  areas  above.  Urinary  contami- 
nations must  be  excluded.  A  better  method  is,  after  thoroughly  clean- 
ing the  vagina,  to  perform  biopsy  or  to  curette  the  vaginal  lesion  and 
examine  the  material  thus  obtained  for  tubercle  bacilli  and  histologic 
evidence  of  the  disease,  or  to  use  this  material  for  animal  inoculation,  or 
preferably  to  employ  both  methods.  Curettage  is  applicable  only  to  the 
ulcerative  variety  of  lesion.  When  possible,  total  excision  of  the  sus- 
pected area  is  preferable  to  any  other  method,  although  no  positive  rules 
can  be  formulated  in  this  respect,  and  curettage  or  the  examination  of 
the  discharge  by  Schultze's  method  may  be  advisable  as  a  preliminary 
step.  In  no  case  in  which  there  is  the  suspicion  of  malignancy  is  delay 
justifiable.  The  presence  of  tuberculosis  in  other  parts  of  the  body,  the 
slow  onset  and  progress  of  the  disease,  and  its  general  chronic  character, 
together  with  the  appearance  of  the  lesion,  should  at  least  lead  to  the 
suspicion  of  this   form  of  infection.      Syphilis,   malignant  neoplasms, 


144        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

chancroid,  the  various  forms  of  vaginitis,  and  in  children  especially, 
gonorrhea,  noma  and  diphtheria  must  be  differentiated. 

Treatment. — This,  in  general,  is  similar  to  that  suggested  for  the 
treatment  of  vulvar  lesions.  In  mild  cases  curettage,  followed  by  the 
application  of  tincture  of  iodin  or  other  chemical  agents,  or  by  the  actual 
cautery,  may  suffice  to  produce  at  least  temporary  relief,  but  excision 
offers  better  hopes  of  a  permanent  cure  in  the  ulcerative  or  hypertrophic 
varieties,  and  may  even  be  employed  for  its  palliative  results,  if  thought 
advisable.  Naturally  much  depends  upon  the  character  and  extent  of 
the  lesion.  Localized  lesions  should,  as  a  rule,  be  excised,  but  when 
large  areas  of  the  vagina  are  involved  this  may  be  impossible,  and  less 
vigorous  methods  may  have  to  be  resorted  to.  In  cases  in  which  the 
upper  genital  tract  is  involved  hysterectomy  may  be  required,  as  it  is 
obviously  difficult  to  cure  a  vaginal  lesion  which  is  constantly  being  re- 
infected by  a  tubercle  bacilli  bearing  uterine  discharge.  Unfortunately, 
the  majority  of  these  cases  are  secondary,  and  treatment  directed  towards 
the  vaginal  condition  is  at  best  but  palliative. 

As  has  been  stated  previously,  many  cases  of  vaginal  tuberculosis  are 
associated  with  vulvar  lesions;  a  similar  association  with  cervical  infec- 
tion is  frequent.  Therefore,  to  obtain  a  full  list  of  all  vaginal  lesions 
the  reader  is  also  referred  to  the  reports  of  tuberculosis  in  both  these 
other  areas. 

CASE  HISTORIES 

Havas.9  Ulcers  were  found  at  the  introitus  vaginae  of  a  27-year-old 
prostitute.  These  were  about  the  size  of  lentils  or  somewhat  smaller, 
rather  deep,  granular,  and  covered  with  a  yellowish  detritus,  with  un- 
dermined edges.  A  diagnosis  of  gonorrhea  had  been  made,  but  this  was 
revised  when  it  was  discovered  that  secretions  from  the  ulcers  yielded 
tubercle  bacilli.  The  ulcers  increased  in  size  slowly,  but  steadily.  The 
patient  was  also  suffering  from  tuberculosis  of  the  lungs. 

Davidsohn.10  Patient  had  general  miliary  tuberculosis,  also  tuber- 
culosis of  the  vagina,  uterus,  and  adnexa.  The  vaginal  mucosa  was  red- 
dened, swollen  and  inflamed.  Scattered  on  the  surface  were  a  number 
of  small  semitranslucent,  yellowish  elevations.  Considerable  discharge 
was  present.  A  number  of  ulcerations  at  the  intravaginal  orifice  were 
also  present.  Histologic  examination  of  the  vaginal  lesion  proved  them 
to  be  miliary  tubercles. 

Zweigbaum.11  Patient  was  32  years  of  age.  She  had  an  ulcer  on 
the  cervix  and,  later,  one  which  involved  the  vagina  and  left  labium 


TUBERCULOSIS  OF  THE  VAGINA  145 

minus.  The  latter  was  of  moderately  large  size.  A  portion  of  one  of 
the  ulcers  was  excised  and  found  to  contain  large  numbers  of  tubercle 
bacilli.  The  patient  subsequently  succumbed  to  pulmonary  and  intestinal 
tuberculosis.  Despite  the  fact  that  the  genital  lesions  antedated  by  some 
months  any  evidence  of  tuberculosis  elsewhere  in  the  body,  Zweigbaum 
very  properly  considered  the  case  a  secondary  one. 

Emanuel.12  Tuberculosis  of  the  vulva  and  vagina  was  secondary  to 
a  cervical  lesion.  The  entire  peritoneum  was  involved  by  an  ulcer.  Tu- 
berculosis was  diagnosed  histologically,  and  tubercle  bacilli  were  dem- 
onstrated.    The  ulcers  were  extremely  extensive. 

Demme.8  Case  1.  A  child  of  seven  months  had  a  tuberculous  ulcer 
at  the  vaginal  orifice.    The  father  was  tuberculous. 

Case  2.  A  child  of  fifteen  months  had  a  mucopurulent  discharge  after 
measles.  An  ulceration  was  present  at  the  entrance  of  the  vagina  which, 
upon  histological  examination,  proved  to  be  of  tuberculous  origin.  An 
inguinal  adenitis  was  present  and  tubercle  bacilli  demonstrated  from  this 
region.    The  child  died  of  pulmonary  tuberculosis. 

Gorfida.13  Primary  Tuberculosis  of  the  Vagina  and  Vulva.  The 
patient  was  a  woman,  23  years  of  age.  Following  the  birth  of  her 
child,  a  laceration  of  the  posterior  vulvar  commissure  was  found.  Two 
months  later  she  noticed  a  sense  of  burning  in  the  vulvar  region,  this 
increased  to- pain,  which  was  attended  with  a  yellowish  discharge.  Noc- 
turnal elevations  of  temperature  and  somewhat  later  a  swelling  in  the 
left  inguinal  region  appeared,  followed  by  an  involvement  of  the  right 
inguinal  lymphatic  glands.  The  external  genitalia  increased  in  size,  espe- 
cially the  right  labium  majus.  The  vaginal  lining  became  thickened  and 
ulcerations,  which,  however,  did  not  involve  the  cervix  or  fornices,  pre- 
sented themselves.  The  uterus  was  normal  in  size  and  anteverted. 
Smears  of  the  vaginal  secretion  revealed  tubercle  bacilli.  The  inguinal 
glands  were  removed  and,  although  cauterized  with  iodin,  the  vaginal 
ulceration  did  not  show  any  improvement.  Finally,  after  curettage  of 
the  ulcer,  the  thermocautery  was  used,  and  the  condition  finally  became 
cured.  Histological  examination  of  the  scrapings  of  the  ulcer  showed 
tuberculous  lesions,  but  no  tubercle  bacilli.  Pieces  of  the  inguinal  glands, 
injected  under  the  skin  of  rabbits,  produced  tuberculosis  in  these  animals. 
The  case  is  interesting  not  only  because  the  ulcerations  were  primary, 
but  because  it  developed  during  the  puerperium.  The  author  believes 
that  the  midwife  transmitted  it  to  the  patient  from  another  case  of  tuber- 
culosis that  she  had  been  attending. 

Karajan.14  Girl,  2  years  old,  whose  hands  were  frequently  on  geni- 
tals.    There  had  been  a  swelling  on  the  genitalia  since  1  year  of  age. 


146        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

No  fever,  cough,  or  diarrhea,  etc.,  were  present.  On  separation  of  the 
swollen  labia  majora  a  penis  shaped  tumor  was  revealed,  which  measured 
3  x  1.5  cm.,  with  small  areas  of  loss  of  tissue  substance,  each  about  the 
size  of  a  pin's  head.  This  tumor  represented  the  clitoris,  the  distal  ex- 
tremity of  which  is  covered  by  an  eczematous  prepuce,  and  had  been 
present  one  year.  Examination  and  voiding  of  urine  caused  pain. 
The  upper  genitalia  were  normal.  The  tumor  was  excised  and  ten 
months  afterwards  the  patient  returned,  showing  a  recurrence  occupying 
the  vestibule  and  vagina.  The  pain  on  urination  had  persisted,  as  had 
also  the  swelling  and  reddening  of  the  external  genitalia.  Painful  in- 
guinal adenitis  was  present,  also  a  tumor,  2  cm.  in  length,  at  the  site  of 
the  scar.  An  ulcer  was  found  on  the  right  side  of  the  vagina.  No  tuber- 
cle bacilli  were  demonstrated  in  the  discharge  from  the  tumor. 
Histologically,  tubercles  with  giant  cells  were  observed  in  the  skin 
and  subcutaneous  tissue  of  the  tumor.  Tubercle  bacilli  were 
present. 

Demme.8  Case  1.  Woman,  aged  39  years.  The  growth  about  the 
vagina  first  began  as  a  small  increase  in  size  of  the  labia  minora,  fol- 
lowed by  small  polypoid  vegetations,  which  grew  slowly  and  obliterated 
the  vagina  completely.  A  large  ulceration  developed  in  the  vestibule  and 
finally  destroyed  the  urinary  meatus  and  urethra.  The  inguinal  glands 
were  not  enlarged.  A  plastic  operation  was  performed.  Giant  cells  and 
tubercle  bacilli  were  found  in  the  vegetation  and  in  the  tissue  of  the 
labia  minora. 

Case  2.  Woman,  aged  50  years.  Six  years  previously  she  had  an 
ulceration  of  the  external  genitalia  with  inguinal  adenitis.  The  patient 
communicated  the  trouble  to  her  husband,  who  died  quickly  of  "tisi  e 
suppurazione  d'airbedue  i  test  coli."  After  some  years  there  appeared 
small  tumefactions  in  the  vulvar  region,  which  was  ulcerated.  The 
vagina  became  involved  and  then  the  clitoris.  The  greater  lips  became 
enlarged  and  wart-like.  A  secondary  tumor  of  the  buttocks  was  present. 
The  entire  tumor  and  hypertrophied  tissue  was  excised.  The  tumefied 
masses  showed  tuberculosis  nodules  histologically,  but  the  sections  of  the 
labia  majora  did  not;  nor  did  those  of  the  clitoris. 

The  following  cases  are  among  those  collected  by  Chaton  :15 

Emanuel.16  Woman,  aged  50  years,  had  miliary  tuberculosis  of  the 
liver,  spleen,  and  peritoneum.  The  uterine  cavity  was  filled  with  caseous 
masses,  and  tuberculous  ulcers  of  the  cervix  and  vagina  were  present. 
The  tubes  and  ovaries  were  normal. 

Rigal.17  The  patient  had  a  miscarriage  at  the  sixth  month  and  died 
shortly  afterwards  from  a  general  miliary  tuberculosis  of  the  lungs, 


TUBERCULOSIS  OF  THE  VAGINA  i47 

peritoneum,  and  meninges.  Tuberculosis  of  the  vagina  and  cervix  were 
present. 

Hamolle.18  Patient  aged  57  years.  She  had  pulmonary  and  peri- 
toneal tuberculosis.  At  autopsy  tuberculosis  of  the  cervix,  uterus,  tubes, 
and  vagina  was  found,  the  disease  manifesting  itself  in  the  latter  locality, 
as  small,  deep  ulcerations,  which  had  undermined  edges,  moderately  firm 
bases,  and  were  chronic  in  appearance.  The  tuberculous  character  of 
her  lesion  was  proven  by  histologic  examination. 

Mosler.19  The  patient  was  an  old  woman  75  years  of  age.  A  pul- 
monary tuberculosis  had  been  present  for  some  time.  The  cervix  and 
vagina  were  the  seat  of  an  ulcerative  lesion,  the  tuberculous  character 
of  which  was  determined  by  histologic  examination.  A  number  of  mil- 
iary tubercles  were  also  present  in  the  vaginal  mucous  membrane.  A 
tuberculous  endometritis  and  adnexitis  were  also  present. 

Weigert.20  The  patient  was  aged  76  years  and  had  pulmonary  and 
peritoneal  tuberculosis.  The  cervix  was  the  seat  of  an  ulcer;  ulcera- 
tions were  also  present  in  the  vagina.  The  tuberculous  character  of  the 
genital  lesion  was  proven  by  histologic  examination. 

Winter.3  The  woman  suffered  from  a  pulmonary  tuberculosis  for 
some  time  prior  to  the  appearance  of  the  genital  lesions.  The  vagina 
was  the  seat  of  tuberculous  ulceration,  the  character  of  which  was 
proven  by  histologic  examination.  The  uterus  and  adnexa  were  also 
involved. 

Jellett  21  reports  the  history  of  a  case  of  extensive  tuberculosis  of  the 
uterus,  adnexa,  and  rectum.    There  was  a  rectovaginal  fistula. 


LITERATURE 


I 
2 

3 
4 
5 
6 

7 
8 

9 
10 
11 
12 


Raynaud.    Arch.  gen.  de  med.     1831.    26:486. 

Babes,  V.    Orvosi  hetil.    1883.   27:163. 

Winter.    Centrbl.  f.  Gyn.    1887. 

Oppenheim.    Inaug.  Dis.   Gottingen,  1889. 

Daurios.     Rev.  Med.-chir.  des  mal.  des  fern.     1891. 

Pozzi,  S.    A  Treatise  on  Gynecology.    1897. 

Schrenk.    Beitr.  z.  Klin.  Chir.    1896.   v.  17. 

Demme.    Wien.  Med.  Bl.    1887.    No.  50. 

Havas,  A.   Centrbl.  f.  Krankh.  d.  Ham-  u.  Sex-Org.  1897.  8:661. 

Davidsohn.    Berl.  Klin.  Woch.   1899.   No.  25. 

Zweigbaum,  M.    Berl.  Klin.  Woch.    1888.    No.  22. 

Emanuel,  R.    Ztschr.  f.  Gebh.  u.  Gyn.    1894.   29:135. 


148        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

13.  Jorfida,   M.     Rif.   Med.     1900.    4:170.     Also  Ann.   de   Gyn.   et 

d'Obst.     55:138. 

14.  Kara jan,  E.  R.  von.    Wien.  Klin.  Woch.     1897.    42.    No.  10,  921. 

15.  Chaton.    Rev.  arch,  de  gyn.    1908.    12:947. 

16.  Emanuel,  R.    Ztschr.  f.  Gebh.  u.  Gyn.    1893. 

17.  Rigal.    Bui.  Soc.  Med.  des  Hop.   May,  1879. 

18.  Hamolle.    Bui.  Soc.  Anat.  de  Paris,  1877. 

19.  Mosler.     Berl.  Klin.  Woch.     1888. 

20.  Weigert.     Virchow's  Arch.  1876.   69:264. 

21.  Jellett,  H.    Lancet,  191 3  :  966. 

ADDITIONAL  BIBLIOGRAPHY 

Mauler.    Beitr.  z.  Gebh.  u.  Gyn.     191 1.     6:485. 
Stockel.     Monats.  f.  Gebh.  u.  Gyn.     1910.    32  (supposedly  a  pri- 
mary case). 
Springer.    Ztschr.  f.  Heil.     1902.    23:1.. 
Daurios.    These  de  Paris.   1889. 
Combeleran,  C.    Inter.  Clin.    1918.  28:158. 
Wichmann,  P.     Derm.  Woch.     1918.    66:33. 


CHAPTER  VIII 

TUBERCULOSIS  OF  THE  CERVIX 

Cases  proved  by  histologic  or  bacteriologic  examination — Forms  of  infection — Primarv 
and  secondary — Causes — Cases  on  record — Coincident  tuberculosis  of  other  parts 
of  genital  tract — Tuberculous  salpingitis  with  or  without  involvement  of  the 
corporeal  endometrium  a  common  accompaniment — Predisposing  causes — Analy- 
sis of  cases  verified  by  histologic  or  bacteriologic  examination — Average  age 
arranged  in  decades — Classification  of  cervical  lesions — Ulcerative,  papillary, 
miliary,  and  interstitial— Analysis  of  cases— Hemorrhage— Pain— Histologic  ex- 
amination—Cases—Tuberculosis of  the  body  of  the  uterus— Endometritis— Bibli- 
ography. 

HISTOLOGIC  AND  BACTERIOLOGIC  EXAMINATIONS 

In  1 83 1,  Raynaud  x  reported  the  history  of  a  case  in  which  the  uterus 
and  adnexa  were  the  seat  of  a  tuberculosis  and  an  ulcer  was  present  on 
the  cervix. 

In  1853,  Virchow  2  reported  the  first  authentic  case  of  tuberculosis 
of  the  cervix,  and  the  following  year  Kiwisch  3  reported  a  similar  case. 
Chaton  4  gives  Rigal  5  credit  for  the  priority  of  recording  the  first  case 
fully  verified  by  histologic  examination.  Since  Virchow's  report,  a  large 
number  of  cases  have  been  recorded.  In  many  of  the  earlier  cases,  how- 
ever, the  diagnosis  is  not  fully  verified  and  even  some  of  the  more  modern 
reports  are  not  above  suspicion.  In  the  formulation  of  trie  statistics 
which  occurs  in  the  following  pages,  care  has  been  observed  to  utilize  only 
such  cases  as  have  been  proved  by  histologic  or  bacteriologic  examina- 
tion. In  many  authentic  cases  important  points  are  lacking,  and  this 
accounts  for  the  different  number  of  cases  utilized  in  the  different  series 
of  statistics. 

Tuberculosis  of  the  cervix  is  a  rare  infection.  Indeed,  Chaton  4  be- 
lieves it  less  frequent  than  vaginal  lesions.  Our  search  through  the  lit- 
erature has  not,  however,  confirmed  this  opinion.  Spath  6  found  that 
the  cervix  was  affected  six  times  in  a  series  of  119  cases  of  genital  tuber- 
culosis occurring  in  the  female;  Mosler,7  in  46  cases  of  like  material, 
found  the  cervix  involved  four  times.  In  the  study  of  66  tuberculous 
gynecological  specimens  in  the  gynecological  laboratory  of  Pathology 
at  the  University  of  Pennsylvania,  all  of  which  have  been  subjected  to 

149 


150   GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

histologic  examination,  there  has  been  I  case  in  which  the  cervix  was  in- 
volved. This,  however,  represents  a  higher  percentage  than  is  usually 
observed. 

Tuberculosis  of  the  cervix  may  be  primary  or  secondary,  the  latter 
being  by  far  the  most  frequent.  It  may  result  from  direct  infection, 
from  extension,  or  may  be  metastatic,  to  use  the  Connheim  expression, 
from  distant  foci  by  way  of  the  blood  or  lymphatics.  In  1902,  Broucha  8 
recognized  only  4  cases  as  primary,  those  reported  by  Klobb,9  Kauf- 
mann,10  Michales,11  and  Broucha  8  and  Chaton,4  in  their  careful  review 
of  the  literature  pertaining  to  this  subject  six  years  later,  were  willing 
to  admit  only  two  additional  cases  (Brooks12  and  Ferrari13).  Of  69 
cases  studied  by  Beyea,14  9  were  apparently  limited  to  the  cervix.  Among 
the  reports  of  90  cases,  the  histories  of  which  have  been  examined  by 
the  author,  14  are  stated  to  have  been  primary,  that  is,  no  other  foci  of 
tuberculosis  was  discovered.  Primary  cervical  tuberculosis  is,  however, 
probably  less  frequent  than  these  figures  would  indicate,  as  it  is  likely 
that  in  not  a  few  of  these  cases  the  original  lesion  has  been  overlooked, 
owing,  perhaps,  to  its  quiescence  or  even  resolution. 

Zweigbaum's  15  case  can  be  pointed  out  as  an  instance  of  this  con- 
dition. At  first  no  other  foci  of  infection  could  be  found,  even  after 
a  thorough  examination.  Zweigbaum,  however,  knowing  the  rarity  of 
primary  lesions  of  the  cervix,  refrained  from  classifying  the  case  as  a 
primary  one.  Subsequently  this  patient  developed  a  general  tuberculosis, 
from  which  she  died.  Other  similar  instances  are  on  record.  The  diffi- 
culty of  sometimes  determining  whether  certain  cases  of  genital  tuber- 
culosis are  primary  or  secondary  has  been  discussed  elsewhere.  A  few 
undoubtedly  primary  cases  have  been  reported,  and  if  we  accept  these, 
it  is  theoretically  possible  for  such  lesions  to  cause  secondary  involve- 
ment of  other  parts  of  the  body.  Such  a  possibility  is,  however,  too 
remote  to  be  considered  of  practical  importance. 

Coincident  tuberculosis  of  other  parts  of  the  genital  tract  is  by  no 
means  uncommon;  thus,  direct  extension  from  the  portio  to  the  vagina 
is  not  infrequent.  Tuberculous  salpingitis,  with  or  without  involvement 
of  the  corporeal  endometrium,  is  a  common  accompaniment  (Frankel le). 
Indeed,  so  often  is  salpingitis  present  that  this  circumstance  has  led 
Montanelli  17  to  recommend  hysterosalpingo-oophorectomy  in  all  cases. 
Numerous  cases  are  on  record  in  which  the  cervical  lesions  have  been 
diagnosed  as  cancer  and  complete  operation  performed,  and  only  after 
the  removal  of  the  specimen,  or  at  operation,  have  the  adnexal  lesions 
been  discovered.  In  some  cases  the  tubes  may  be  normal  and  the  only 
other  genital  lesion  an  endometritis. 


TUBERCULOSIS  OF  THE  CERVIX 


I5I 


The  frequency  of  the  latter  complication  is  disputed  by  many  au- 
thorities, some  believing  it  common,  and  others  remarking  upon  its 
rarity.  It  appears,  however,  that  the  more  thoroughly  these  cases  are 
examined,  the  more  frequently  are  corporeal  lesions  discovered,  and 
this  is  in  accord  with  what  would  be  expected  from  a  study  of  the  biology 
of  tubercle  bacilli  and  the  anatomic  relationship  of  these  two  areas. 
Tuberculosis  by  extension  is  relatively  by  no  means  infrequent  in  the 
external  genitalia,  vagina,  and  cervix,  and  extension  from  the  corporeal 
endometrium  downward  or  from  the  cervix  upward  is  not,  therefore, 
surprising.  Lepitit 18  believes  that  in  his  case  the  disease  spread  from 
the  cervix  to  the  body  of  the  uterus. 

In  a  study  of  47  cases  of  cervical  tuberculosis,  involvement  of  some 
portion  of  the  genital  tract  above  the  internal  os  was  reported  in  36. 
Veyrat,19  in  a  series  of  89  cases  of  cervical  tuberculosis  studied,  found 
pulmonary  lesions  present  in  42  per  cent.  Lung  lesions  are  naturally 
the  most  frequent  primary  foci,  but  numerous  other  localities  have  been 
recorded.  Thus  Kromer  20  reports  a  case  in  which  the  only  other  focus 
of  disease  was  a  cutaneous  lesion  on  the  buttock.  In  Fabricius's  21  case 
an  intestinal  lesion  was  present  and  a  hairpin  had  been  introduced  into 
the  rectum,  perforated  the  vagina,  and  penetrated  the  cervix;  and  in 
the  wound  on  the  latter  a  typical  tuberculous  ulcer  developed.  A  num- 
ber of  authors  have  attributed  their  cases  to  direct  infection  through 
coitus,  the  husbands  of  these  women  presenting  genital  tuberculosis 
(Glockner22  and  Michales11).  Frank23  believes  the  infection  in  his 
case  was  communicated  by  the  hand  or  by  soiled  linen ;  this,  however,  is 
questionable,  as  the  patient  gave  a  history  of  a  previous  tuberculous  bone 
disease. 

Predisposing  Causes. — Beyond  the  presence  of  tuberculosis  in  other 
parts  of  the  body  and  especially  of  the  genital  tract,  little  is  known  re- 
garding the  predisposing  causes  to  cervical  infection.  An  analysis  of 
29  cases,  all  of  which  were  verified  by  histologic  or  bacteriologic  exam- 
ination, showed  that  5  occurred  in  virgins,  17  in  nulliparas,  and  7  in 
multiparas.  In  a  larger  series  of  cases,  in  all  of  which  the  diagnosis 
was  not  positive,  the  proportion  of  multiparas  was  found  to  increase 
very  materially ;  indeed  Chaton  4  states  that  patients  affected  with  tu- 
berculosis of  the  cervix  are  usually  multiparas.  It  would  seem,  how- 
ever, that  lacerations,  or  rather  the  result  of  laceration,  such  as  cicatricial 
tissue,  hypertrophies,  and  eversions,  play  but  a  small  part  in  the  etiology 
of  this  condition.  There  seems  to  be  little  doubt  that  recent  laceration 
and  trauma,  by  the  production  of  loss  of  continuity  and  the  opening  up 
of  avenues  of  infection,  and,  perhaps,  by  producing  areas  of  lessened 


152        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

resistance,  are,  to  a  certain  extent,  predisposing  agents,  Braye's  24  and 
Rigal's25  cases  followed  miscarriages  of  three  and  six  months,  respec- 
tively. Thiercelin's  26  case  also  followed  a  miscarriage.  Animal  experi- 
ments bear  out  the  assertion  that  loss  of  continuity  and  trauma  are  pre- 
disposing agents  to  infection  by  the  tubercle  bacillus.  Martin  27  remarks 
upon  the  strangeness  of  the  fact  that  tuberculosis  does  not  follow  the 
emptying  of  the  pregnant  uterus  more  frequently  in  cases  known  to  have 
tubercle  bacilli  in  the  uterine  discharge.  Preexisting  inflammation  prob- 
ably plays  an  important  part  as  a  predisposing  agent.  This  is  an  estab- 
lished factor  in  the  production  of  vaginal  and  vulvar  lesions,  as  well  as 
in  tuberculous  salpingitis. 

No  age  is  immune;  the  disease,  however,  is  most  frequently  met 
during  the  active  sexual  life.  An  analysis  of  116  cases  shows  that  the 
average  age  was  29.3  years,  the  extremes  being  three  years  (Mosler7), 
72  and  75  years  (Kaufmann10  and  Menetrier  28).  Arranged  in  dec- 
ades, the  116  cases  present  the  following  results  : 


Years 

Cases 

Per  Cent 

1  to 

10 

2 

1.8 

11  " 

20 

6 

5-3 

21  " 

30 

60 

53-1 

31   " 

40 

25 

22.5 

41   " 

50 

11 

9-9 

51  " 

60 

4 

3-6 

61  " 

70 

6 

5-3 

71   « 

80 

2 

1.8 

These  statistics  closely  coincide  with  those  of  Beyea,14  Chaton,4  and 
Lannes-Dehore,29  who  found  the  greatest  number  of  cases  occurring 
between  21  and  41  years  of  age.  Hager  (quoted  by  Chaton4),  Alter- 
thum,30  Morlitte,31  Landouzy  (quoted  by  Chaton4)  and  Fournier 
(quoted  by  Chaton4)  believe  that  hypoplasia  or  faulty  development  of 
the  genital  tract  is  to  some  extent  a  causative  agent  in  the  development  of 
cervical  tuberculosis.  In  cases  examined  by  the  author  no  such  connec- 
tion was  determinable. 

Symptoms. — Cervical  tuberculosis  being  usually  secondary,  symp- 
toms of  pulmonary  lesions  are  frequently  present,  while  a  history  sug- 
gestive of  a  general  or  pelvic  peritonitis  is  by  no  means  uncommon 
As  a  result  of  a  primary  lesion  in  other  parts  of  the  body,  the  patients 


TUBERCULOSIS  OF  THE  CERVIX  153 

are  often  emaciated  and  may  suffer  from  pyrexia,  hemoptysis,  anorexia, 
night  sweats,  etc.  None  of  the  symptoms  resulting  from  the  cervical 
lesions  are  pathognomonic.  Discharge,  hemorrhage,  and  occasionally 
pain  or  itching,  constitute  the  symptom  complex.  Amenorrhea,  which 
is  present  in  a  considerable  proportion  of  cases,  is  generally  due  to  other 
factors  than  the  cervical  lesion,  such  as  the  menopause,  an  occlusion  in 
the  cervical  canal  causing  a  pyometra,  or  it  may  be  secondary  to  a  pul- 
monary lesion.  Amenorrhea  was  present  in  42  per  cent  of  the  28  cases 
of  cervical  tuberculosis  studied  by  Murphy.39 

Discharge. — If  the  disease  be  advanced,  more  or  less  discharge 
is  certain  to  be  present.  This  varies  from  a  thin,  irritating  leukorrhea 
to  a  thick  fetid,  glairy,  material.  As  necrosis  advances,  the  discharge 
usually  becomes  yellowish  or  brownish,  and  may  contain  cheesy  par- 
ticles. As  a  rule  the  discharge  is  malodorous  but  is  occasionally  in- 
offensive, especially  in  the  early  stages  before  much  destruction  of  tissue 
has  occurred.  Not  infrequently  it  may  be  blood  streaked;  this  is  espe- 
cially likely  to  be  the  case  following  trauma.  In  the  interstitial  and 
miliary  varieties,  discharge  is  a  less  marked  feature,  and  is  rarely  san- 
guineous. As  a  result  of  the  discharge  itching  and  burning  in  the 
vagina  and  about  the  external  genitalia  may  occur,  while  a  well  marked 
pruritus  vulvae  and  lesion  of  the  vagina  and  external  genitalia  may 
result. 

Hemorrhage. — Variations  in  the  menstrual  cycle,  as  to  periodicity 
and  amount  lost,  are  by  no  means  infrequent,  but  are  usually  the  result 
of  a  corporeal  endometritis  or  adnexitis.  If  the  primary  focus  be  in 
the  lungs,  menstrual  disturbances  from  this  source  are  frequent.  This 
latter  condition  will  be  described  in  detail  in  a  subsequent  chapter. 

The  hemorrhages  produced  by  the  cervical  lesion  in  themselves  vary 
markedly,  but  are  usually  in  the  form  of  "spottings"  and  follow  trauma, 
such  as  examination,  coitus,  etc.  In  some  cases  the  lesions  have  shown 
little  tendency  to  bleed,  while  in  others  a  vascularity  and  friability 
strongly  suggestive  of  carcinoma  have  been  present.  As  would  be  ex- 
pected, the  miliary  and  interstitial  varieties  are  less  prone  to>  produce 
hemorrhage  than  are  the  ulcerative  and  papillary. 

Pain. — Since  the  cervix  contains  few  sensory  nerves,  pain  is  rarely 
a  marked  feature.  As  the  disease  advances  and  absorption  takes  place 
a  cellulitis  of  the  base  of  the  broad  ligament,  with  its  resulting  symp- 
toms, is  by  no  means  uncommon.  As  a  result  of  lesions  in  the  upper 
genital  tract  and  pelvic  peritoneum,  pain  in  the  lower  abdomen  is  not 
infrequently  encountered.  As  a  result  of  the  cervical  lesion,  occlusion 
of  the  cervical  canal  may  occur,  and  result  in  a  pyometra,  as  in  one 


154        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

of  the  cases  of  Pollosson  and  Violet.40  If  this  occurs,  enlargement  of 
the  uterus  and  more  or  less  pain  is  prone  to  occur.  Spread  to  the  adnexa 
and  pelvic  peritoneum,  produces  the  symptoms  characteristic  of  these 
lesions.  The  macroscopic  appearances  of  the  different  varieties  of 
cervical  tuberculosis  naturally  vary  widely. 

Varieties. — Pozzi  describes  three  varieties,  the  ulcerative,  vegetative, 
and  miliary,  to  which  Schutt  32  has  added  a  catarrhal  form,  examples  of 
which  are  the  cases  of  Meyer,33  Giglio,34  Sippel,35  and  Schutt.  This 
variety  is  rejected  by  Chaton.4  Cotte  36  has  described  an  inflammatory 
variety  which  closely  simulates  an  endocervicitis,  glandular,  periglandu- 
lar inflammation  and  changes  in  the  surface  epithelium  being  the  chief 
features. 

The  most  satisfactory  classification  is  that  which  divides  the  cervical 
lesions  into  four  groups,  the  ulcerative,  the  papillary,  the  miliary,  and 
the  interstitial.  Of  these,  the  ulcerative  and  papillary  are  the  most  fre- 
quent, the  miliary  and  interstitial  being  comparatively  rare  varieties. 
An  analysis  of  106  cases  shows  52  to  have  been  ulcerative,  41  papillary, 
7  miliary,  and  6  interstitial.  These  statistics  are,  however,  to  some  ex- 
tent misleading,  as  combinations  of  the  various  forms,  especially  the 
ulcerative  and  papillary,  have  been  present  frequently;  while  it  is  prob- 
able that,  if  these  cases  could  have  been  examined  in  their  incipiency, 
the  interstitial  and  even  perhaps  the  miliary  would  have  been  found  more 
often.  The  interstitial  variety,  like  the  similar  form  of  cervical  cancer, 
does  not  produce  marked  symptoms  until  the  disease  has  broken  through 
to  the  surface  of  the  portio  or  the  canal,  and  when  examined  at  this 
latter  time,  is  doubtless  frequently  classed  as  the  ulcerative  variety. 

Chaton,  in  his  analysis  of  cases,  found  37  ulcerative,  22  papillary, 
and  7  miliary.  Cova  37  thinks  the  papillary  variety  frequently  presents 
ulcerations.  Patel 38  states  that  50  per  cent  of  the  cases  are  of  the 
ulcerative  variety.  In  the  secondary  cases,  the  cervical  lesions  do  not 
necessarily  follow  the  type  of  the  original  foci.  Thus  a  general  miliary 
tuberculosis  may  result  in  an  ulcerative,  papillary,  or  other  form  of  lesion. 

An  analysis  of  14  primary  cases  showed  8  to  be  of  the  ulcerative 
variety  and  6  of  the  papillary.  It  is  doubtful  if  all  of  these  cases  are 
primary.  Not  infrequently  specimens  are  reported  as  primary  upon 
insufficient  evidence. 

Beyea  14  analyzed  59  cases  of  cervical  tuberculosis  with  a  view  to 
ascertaining  the  portion  of  the  cervix  attacked.  In  these  the  portio  was 
involved  alone  in  11,  the  supravaginal  cervix  alone  in  6,  and  both  in 
42.  The  primary  lesion  in  the  cervix  is  usually  in  the  canal,  regardless 
of  the  variety. 


TUBERCULOSIS  OF  THE  CERVIX  155 

Ulcerative  Variety. — These  lesions  vary  considerably  in  size  and 
appearance.  In  some  specimens  they  are  large  and  the  place  of  the 
entire  vaginal  cervix  is  occupied  by  the  ulcer,  as  in  the  case  of  Bonilly.41 
Not  infrequently  the  adjacent  vagina  is  involved.  In  other  instances 
the  ulcers  are  small  and  may  resemble  a  chancroid,  as  in  the  case  of 
von  Franque.42  Usually  the  external  os  is  the  starting  point,  the  dis- 
ease spreading  from  this  location  toward  the  vagina  eccentrically.  The 
lesions  may  be  situated  upon  the  portio  or  in  the  cervical  canal.  In  the 
cases  of  Nanard,43  and  Broucha  8  the  ulcers  were  almost  entirely  within 
the  cervical  canal.  Or  the  lesion  may  commence  on  the  portio  and 
spread  upward,  involving  the  endometrial  cavity,  as  in  the  case  of 
Lepitit,18  or  the  converse  may  be  the  case. 

In  some  instances  the  lesions  are  shallow  and  surrounded  by  clean 
cut,  slightly  raised  margins ;  more  frequently,  and  especially  in  advanced 
cases,  the  ulcers  are  moderately  deep  and  present  roughened,  swollen, 
and  often  undermined  edges.  The  base  and  edges  may  be  fairly  smooth 
and  contain  numerous  raised  concentric  elevations,  often  yellowish  and 
grayish  and  partially  translucent;  or  the  sides  and  base  may  be  cov- 
ered with  darkened,  necrotic  material  and  a  general  worm-eaten  appear- 
ance be  present,  or  the  surface  of  the  ulcer  may  be  granular.  Occa- 
sionally there  is  attached  to  the  ulcer,  yellowish,  cheesy  material.  The 
ulcers  may  be  multiple,  but  are  more  frequently  single.  The  lesions 
usually  bleed  moderately,  easily,  although  in  a  few  instances  this  sign 
has  been  absent.  As  a  rule  the  bleeding  is  less  marked  than  in  carci- 
noma and  the  lesions  appear  more  chronic.  On  palpation  the  base  of 
the  ulcer  generally  presents  a  soft  velvety  feel.  The  friable  character 
can,  however,  frequently  be  detected  by  the  touch.  The  cervix  is  gen- 
erally enlarged. 

Papillary. — In  this  form  there  is  an  outgrowth  from  the  cervix  of 
more  or  less  cauliflower-like  masses;  when  first  examined  these  are 
usually  dark,  reddish  or  brownish  in  color  and  covered  by  discharge. 
Not  infrequently  nodular  elevations,  sometimes  of  moderate  size,  are 
present.  If  the  latter  be  removed,  or  after  excision,  these  are  found 
to  be  papilloma-like  masses,  red,  yellow,  gray,  pink,  or  white,  often  some- 
what translucent,  and  frequently  contain  areas  of  necrosis.  The  papil- 
lary variety  generally  affects  the  portio,  but  may  originate  from  the 
cervical  canal.  As  a  rule  this  type  is  moderately  friable,  and  as  a  re- 
sult bleeds  easily.  In  some  cases,  however,  especially  when  small,  and 
before  much  breaking  down  has  occurred,  the  masses  are  moderately 
firm  and  exhibit  but  little  tendency  to  bleed  on  touch.  The  papillomata 
may  spring  from  a  broad  base  or  more  rarely  be  definitely  peduncu- 


156        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

lated.  They  may  be  single  or  multiple.  In  some  instances  there  is  a 
papillary  endocervicitis,  and  more  or  less  spreading  outwards  through 
the  external  os  of  small  polypoid  masses,  as  in  the  cases  of  Pollosson,40 
Beyea,14  and  Lewers ; 44  or  the  outgrowths  may  originate  from  the 
portio,  as  in  the  cases  of  Cornil  45  and  Giglio.34 

Emanuel,40  Ferrari,13  also  Ressegna  47  and  Vitrac  48  have  observed 
a  form  that  exists  as  a  distinct  tumor,  more  or  less  pedunculated  and 
friable,  the  origin  of  which  is  variable,  but  usually  from  the  portio. 
This  has  been  described  by  some  of  the  French  writers  as  the  "vege- 
tante  neoplastique"  variety.  In  many  specimens  the  fungus-like  masses 
closely  resemble  carcinoma.  The  cervix  is  usually  enlarged  and  the 
surface  of  the  portio  not  covered  by  outgrowths  is  reddened.  Some- 
times this  variety  affects  the  external  os,  as  in  the  case  of  Hofbauer,49 
and  sometimes  the  canal  (Beyea14  and  Lewers44).  Pollosson  and 
Violet 40  especially  emphasize  the  fact  that  the  disease  may  occur  as 
a  localized  intracervical  polypoid  condition. 

Miliary. — In  this  variety  the  cervix  is  enlarged,  reddened,  turbid, 
and  small,  somewhat  pale  yellowish,  or  grayish,  partially  translucent  ele- 
vations may  be  seen  beneath  the  surface  epithelium.  These  are  usually 
solid,  but  may  contain  turbid  fluid  or  cheesy  material.  The  mucosa  at 
the  external  os  may  be  normal  or  may  be  thickened,  swollen  and  in- 
flamed. In  some  instances  the  tubercles  are  limited  to  the  mucosa  of 
the  canal,  but  more  frequently  the  portio  is  also  involved.  The  surface 
of  the  portio  between  the  tubercles  sometimes  presents  a  granular  ap- 
pearance, and  a  general  tendency  towards  fibrosis  is  often  observed. 
Instructive  reports  on  this  variety  of  lesion  may  be  found  in  the  con- 
tributions of  Rigal,5  Cornil,50  Zweigbaum,15  Denville,51  Vitrac,48  and 
Bouffe.52 

Interstitial. — This  variety  begins  in  the  substance  of  the  cervix, 
which  becomes  enlarged,  usually  asymmetrically.  As  the  disease  ad- 
vances, a  localized  necrosis  occurs,  which  eventually  breaks  down  into 
the  canal,  or  more  often  on  to  the  portio,  leaving  a  ragged,  undermined 
opening  leading  into  the  primary  cervical  focus.  In  the  latter  stages, 
a  deep,  undermined  ulcer  is  present,  which  is  lined  by  necrotic  tissue, 
blackish  or,  in  some  instances,  yellowish  in  color.  Tubercles  may  be 
present  in  the  friable  floor  or  walls  of  the  cavity  and  in  the  adjacent 
surface. 

Combinations  of  these  varieties  are  frequent,  especially  of  the 
ulcerative  and  papillary. 

Diagnosis. — As  has  been  stated,  tuberculosis  of  the  cervix  produces 
no  symptoms  that  are  by  any  means  pathognomonic.     In  no  case  can  a 


TUBERCULOSIS  OF  THE  CERVIX 


157 


positive  diagnosis  be  arrived  at  without  the  aid  of  the  microscope.  The 
majority  of  cases  have  been  diagnosed  clinically  as  carcinoma  and  the 
true  character  of  the  lesion  ascertained  only  by  a  histologic  examination. 


Tuberculosis  of  the  cervix 

Carcinoma  of  the  cervix 

No  age   is  immune.     Most    fre- 
quent in  active  sexual  life. 

Rare  in  the  extremes  of  life. 
Most  frequent  between  35  and 
50  years. 

Such  history  is  infrequent. 

There  is  a  history  of  tuberculosis 
in  other  parts  of  the  body,  in  the 
majority  of  cases. 

Nullipara  by  no  means  immune. 

Extremely  rare  in  women  who 
have  never  been  pregnant. 

Local  symptoms  may  have  been 
present  for  a  prolonged  period. 

Tubercles  may  often  be  observed 
in  the  lesion  or  on  the  adjacent 
structures. 

Course  of  the  disease  more  rapid. 

Tubercles  absent. 

The  margin  of  the  ulcer  is  usu- 
ally undermined  and  fairly  soft. 

Floor  of  the  ulcer  is  moderately 
soft  and  may  contain  numerous 
macroscopic  grayish  or  yellowish 
semitranslucent  tubercles. 

Usually  elevated  and  indurated. 

Hard  and  nodular.  Tubercles 
are  absent. 

Usually  bleeds  readily  but  not  al- 
ways. 

Bleeds  more  readily. 

The  discharge  may  contain  cheesy 
masses    and    tubercle    bacilli,    as 
shown  by  staining,  inoculation,  or 
culture. 

Necrotic  tissue,  which  presents 
the  histologic  characteristics  of 
cancer.     Tubercle  bacilli  absent. 

As  stated  above,  tuberculous  lesions  of  the  cervix  are  usually  softer 
and  less  indurated  than  carcinoma.     The  appearance  and  friability  may 


158        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

be  suggestive  of  carcinoma,  but  the  less  indurated  and,  indeed,  often 
velvety  sensation  of  the  tuberculosis  is  usually  in  marked  contrast  to 
the  cancer.  Even  if  distinct  nodules  are  present,  these  are  usually  softer 
than  cancer.  To  the  experienced  surgeon  this  is  a  valuable  sign  and 
should  in  itself,  at  least,  suggest  the  possibility  of  tuberculosis.  In  ex- 
amining the  literature  pertaining  to  this  subject,  the  reader  cannot  fail 
to  be  impressed  with  the  frequency  with  which  this  differential  diag- 
nostic point  is  mentioned. 

Despite  the  above  differences,  many  cases  will  be  encountered,  in 
which  a  clinical  differentiation  is  impossible,  and  in  all  in  which  doubt 
exists,  biopsy  should  be  resorted  to,  the  excision  being  performed  with 
a  cautery  knife  heated  to  a  dull  red.  As  carcinoma  is  so  much  more 
frequent  than  tuberculosis,  this  fact  should  be  borne  in  mind,  and  no 
time  lost  in  arriving  at  a  diagnosis.  In  not  a  few  cases,  tuberculosis  of 
the  cervix  has  been  clinically  mistaken  for  sarcoma  (Cornil,50  Frankel,16 
Kaufmann,10  Giglio,34  Vitrac,48  and  Emanuel46)  and  its  true  character 
only  recognized  after  histologic  examination. 

In  addition  to  the  differentiation  from  malignant  neoplasms,  the  ul- 
cerative and  papillary  varieties  must  be  distinguished  from  lacerations, 
hypertrophies  or  eversion  the  result  of  childbirth,  other  inflammations 
such  as  gonorrhea,  chancre,  and  the  papular  and  ulcerative  syphilides, 
gumma,  chancroid,  condylomata  acuminata,  benign  polyp,  leukoplakia, 
nbromyomata,  and  sarcoma.  With  the  exception  of  the  last  named,  no 
great  difficulty  exists  in  excluding  these  conditions. 

The  miliary  variety  must  be  distinguished  from  other  inflammatory 
lesions,  especially  when  the  latter  are  associated  with  laceration  and 
eversion,  or  nabothian  cysts,  hypertrophies,  and  subinvolution. 

The  interstitial  variety,  if  observed  in  its  early  stages,  may  be  con- 
fused with  interstitial  neoplasms,  retention  cysts,  laceration  or  hyper- 
trophies. The  differential  diagnosis  between  tuberculosis  of  the  cervix 
and  the  above  named  conditions,  with  the  exception  of  the  malignant 
neoplasms,  usually  presents  no  unusual  difficulties. 

Prognosis. — If  tuberculosis  of  the  cervix  be  primary  and  localized, 
the  prognosis  is  favorable,  provided  the  proper  treatment  be  adopted. 
In  determining  that  a  given  case  is  primary,  extreme  caution  should 
be  observed.  As  the  great  majority  of  cases  are  secondary,  the  prog- 
nosis depends  to  a  large  extent  upon  the  character  of  the  primary 
lesion.  As  a  general  rule,  in  secondary  cases  the  prognosis  is  grave; 
however,  cures  have  been  reported  in  a  number  of  instances. . 

In  the  great  majority  of  the  reported  cases  the  ultimate  outcome 
is  not  stated.     Beyea's 14  statistics  show  that,  out  of  10  cases  subjected 


TUBERCULOSIS  OF  THE  CERVIX  i59 

to  panhysterectomy,  3  died  soon  after  the  operation — 1  from  shock,  1 
from  tuberculous  peritonitis,  and  1  from  an  aggravation  of  the  lung 
condition :  of  the  7  remaining,  6  were  well  some  years  after  the  opera- 
tion; and  in  1  four  months  had  elapsed.  Statistics  of  this  type  are, 
however,  misleading.  The  chief  condition  in  the  large  proportion  of 
cases  being  the  primary  focus,  its  extent,  character,  amenability  to  treat- 
ment, the  apparent  virulence  of  the  infection,  the  patient's  age,  social 
status,  etc.,  are  all  points  which  should  be  considered  in  rendering  the 
prognosis,  as  well  as  the  condition  of  the  upper  genital  tract. 

Treatment. — This,  also,  is  dependent  upon  whether  the  case  is 
primary  or  secondary.  In  the  former  event  a  panhysterectomy  or,  if 
the  lesion  is  small  and  entirely  limited  to  the.  vaginal  cervix,  a  high 
trachelectomy,  is  indicated.  If  the  latter  operation  is  selected,  a  curet- 
tage should  be  performed  and  the  curettings  from  the  body  of  the  uterus 
examined  histologically  for  the  purpose  of  excluding  a  tuberculous  endo- 
metritis. If  curettage  is  performed,  especial  precaution  should  be  in- 
stituted to  prevent  carrying  tubercle  bacilli  from  the  cervix  to  the 
endometrial  cavity.  As  an  additional  safeguard,  it  is  advisable,  as  a 
final  step  in  the  curettage,  to  apply  tincture  of  iodin  to  the  denuded 
uterine  cavity.  In  patients  past  the  child  bearing  period,  or  who  al- 
ready have  a  number  of  children,  an  abdominal  panhysterectomy  is  pref- 
erable in  most  cases,  for  by  this  means  a  thorough  examination  can  be 
made  and  the  condition  of  the  adnexa  ascertained  beyond  the  question 
of  a  doubt.  The  exposure  of  the  peritoneum  to  the  air  is  also  of  ad- 
vantage in  cases  in  which  either  general  or  local  peritonitis  is  present. 

Chaton  4  and  Petit-Dutaillis  53  favor  the  vaginal  route  in  these  cases. 
The  former  states  that  in  15  vaginal  hysterectomies  there  were  2  deaths; 
and  among  8  abdominal  hysterectomies  2  deaths  occurred  and  2  local 
recurrences.  The  question  of  which  route  shall  be  selected  is  largely 
a  matter  of  choice  with  the  individual  surgeon.  The  author  prefers 
the  abdominal  route.  The  fact  that  the  corporeal  endometrium  and 
the  adnexa  are  involved  in  the  tuberculous  process  in  a  large  propor- 
tion of  cases  should  also  be  borne  in  mind  in  selecting  the  operation. 
Patel 54  especially  recommends  excision  in  the  hypertrophic  varieties 
of  the  disease.  In  cases  in  which  there  is  involvement  of  the  upper 
genital  tract  or  peritoneum,  hysterectomy  is  generally  the  most  satis- 
factory operation. 

If  pulmonary  phthisis  or  other  distinct  foci  are  present,  their  extent 
and  character  should  decide  the  treatment  to  a  large  extent.  Palliative 
measures  are  usually  preferable  in  advanced  cases.  The  amount  of 
discomfort  produced  by  the  genital  lesion  must,  however,  be  considered. 


i6o        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

In  this  respect,  each  case  is  more  or  less  a  law  unto  itself.  The  general 
tendency  is  very  properly  to  treat  these  cases  surgically  when  the  primary 
focus  is  of  such  a  character  as  to  permit  operation.  This  subject  of 
treatment  of  secondary  lesions  will  be  more  thoroughly  considered  under 
a  separate  heading  in  a  subsequent  chapter.  Murphy  39  states  that  of 
ii  cases  treated  palliatively,  I  recovered,  5  were  temporarily  improved, 
and  in  5  the  disease  progressed.  Petit-Dutaillis  53  has  reported  the  his- 
tory of  one  case  which  recurred  six  years  after  a  curettage  and  cauter- 
ization with  the  actual  cautery.  In  1903,  Murphy39  advised  against 
hysterectomy  in  primary  cases,  stating  that  the  operation  gave  a  30  per 
cent  mortality.  We  feel  that,  with  our  present  methods  of  operating  in 
uncomplicated  cases,  this  is  far  in  excess  of  the  actual  figures,  and  that 
three  or  four  per  cent  would  be  the  maximum  under  favorable  cir- 
cumstances. 

Curettage  of  the  cervix,  followed  by  cauterization,  either  with  a 
zinc  chlorid  or  preferably  with  the  actual  cautery,  may  be  employed  as 
a  palliative  measure  in  cases  with  advanced  primary  lesions.  Radium, 
or  the  Rontgen  rays  have  apparently  produced  good  results  in  some 
cases.  Radium  or  the  X-Rays  are  positively  contraindicated,  if  a  sal- 
pingitis is  present.  Under  such  circumstances  either  of  these  methods 
of  treatment  is  prone  to  light  up  the  infection  and  produce  serious  con- 
sequences. In  these,  as  in  all  other  cases  of  genital  tuberculosis,  par- 
ticularly in  the  secondary  variety,  the  after  treatment  is  of  the  utmost 
importance.     This  will  be  considered  in  detail  in  a  subsequent  chapter. 


CASE  HISTORIES 

Haultin.55  Single,  35  years  of  age.  Menstruation  was  normal. 
For  several  months  there  had  been  increasing  leukorrhea.  Examina- 
tion of  the  cervix  showed  it  to  possess  a  rough,  irregular  outline,  not 
friable,  and  did  not  bleed  easily.  It  was  purplish  in  color,  and  more 
or  less  covered  with  papillomatous  outgrowths  and  bathed  in  a  thick, 
yellowish  discharge.  The  body  of  the  uterus  was  normal.  A  high 
trachelectomy  was  performed.  The  specimens  showed  the  usual  histo- 
logic picture  of  tuberculosis,  and  tubercle  bacilli  were  demonstrated  in 
the  tissue  by  staining.  The  case  is  of  especial  interest,  as  it  was  ap- 
parently primary.  No  history  or  physical  evidence  of  tuberculosis  in 
any  other  parts  of  the  body  could  be  demonstrated.  Furthermore,  the 
patient  was  well  sixteen  years  after  the  operation.  The  fact  that  she 
was  single,  and  that  the  hymen  was  intact  would  tend  to  exclude  the 


TUBERCULOSIS  OF  THE  CERVIX  161 

ordinary  routes  of  direct  infection.  The  most  pronounced  histologic 
changes  were,  however,  on  the  portio  vaginalis. 

Montanelli 17  furnishes  brief  records  of  eleven  cases  of  tuberculosis 
of  the  cervix  uteri,  from  the  Royal  obstetricogynecological  clinic  at 
Florence,  reporting  two  of  these  cases  in  detail. 

Case  I.  Patient  aged  38  years  and  nullipara,  in  whom  the  onset  of 
menstruation  had  been  delayed.  The  menses  were  abundant  and  fre- 
quent.    She  had  leukorrhea  and  papillary  tuberculosis  of  the  cervix. 

Case  2.  Woman,  aged  41  years  and  nullipara.  The  menses  were 
always  irregular,  had  leukorrhea,  and  bleeding  after  coitus.  Interstitial 
tuberculosis  of  the  cervix  with  marked  glandular  hyperplasia  was  pres- 
ent. 

Case  3.  Woman  aged  40  years,  and  had  one  child.  The  patient 
had  leukorrhea  for  eight  months,  and  sometimes  bleeding.  Papillary 
tuberculosis  of  the  cervix  was  diagnosed. 

Case  4.  Patient  aged  39  years  had  tuberculosis  of  the  peritoneum, 
adnexa,  and  cervix. 

Case  5.  Woman  aged  18  years  and  nullipara.  She  had  abdominal 
pains,  and  amenorrhea  had  existed  for  six  months.  Papillary  tubercu- 
losis of  the  cervix  was  diagnosed,  with  partial  ulceration. 

Case  6.  Woman,  aged  44  years,  and  decipara.  The  patient  had 
leukorrhea,  and  abdominal  pains.  Interstitial  tuberculosis  of  the  cervix 
with  involvement  of  the  body  of  the  uterus,  adnexa,  and  peritoneum,  was 
present. 

Case  7.  Patient  aged  26  years,  was  a  nullipara,  and  had  irregular 
menses  and  caseous  masses  in  the  uterine  cavity.  Papillary  tuberculosis 
of  the  cervix,  and  tuberculosis  of  the  adnexa  and  peritoneum  were 
present. 

Case  8.  A  woman,  aged  25  years,  who  had  been  married  three 
years,  but  had  never  been  pregnant,  sought  advice  for  amenorrhea,  which 
had  persisted  for  some  months.  Examination  showed  the  body  of  the 
uterus  normal  in  size  and  position.  On  the  portio  was  an  erosion  which 
bled  easily  and  a  polyp  protruded  from  the  external  os.  Curettage  and 
histologic  examination  verified  the  diagnosis  and  panhysterectomy  and 
bilateral  salpingo-oophorectomy  was  performed.  The  cervix,  the  body 
of  the  uterus,  and  the  right  tube  were  found  to  be  tuberculous. 

Case  9.  This  patient  was  a  sterile  married  woman  of  28  years. 
Menstruation  was  irregular  for  two  years.  The  last  period,  five  months 
ago,  was  followed  by  profuse  leukorrhea.  The  uterus  was  normal  in 
size.  The  cervix  was  the  seat  of  a  papillary  growth,  which  bled  easily. 
No  tuberculous  lesion  could  be  detected  in  any  part  of  the  body,  nor  had 


162        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

there  been  fever  for  fourteen  days  prior.  The  inguinal  glands  were 
slightly  enlarged.  Panhysterectomy  was  performed  and  tuberculosis 
histologically  demonstrated  in  the  cervix,  endometrium  and  tubes. 

Case  10.  Woman,  aged  51  years,  and  nullipara.  The  menopause 
occurred  at  46  years  and  had  had  a  bloody  discharge  for  the  last  seven 
months.     Papillary  tuberculosis  of  the  cervix  was  diagnosed. 

Case  11.  Woman,  aged  39  years  and  nullipara.  The  patient  had 
abdominal  pains  and  leukorrhea.  The  condition  was  diagnosed  as 
papillary  tuberculosis  of  the  cervix. 

Montanelli 17  believes  the  cervical  lesions  are  often  secondary  to  sal- 
pingitis and  therefore  recommends  panhysterectomy  and  bilateral  sal- 
pingo-oophorectomy  in  all  cases. 

Alterthum.30  Woman,  aged  36  years  and  married,  had  abdominal 
pains  and  polypoid  elevations  on  the  posterior,  cervical  lip.  Extensive 
pelvic  inflammatory  disease  was  present.  On  microscopic  examination, 
tuberculosis  of  the  polyp  was  diagnosed.  The  author  makes  no  claim 
for  the  primary  occurrence  on  the  cervix  in  this  case. 

Smith.56  A  nullipara,  aged  25  years,  believed  to  have  had  a  two 
and  a  half  months'  abortion  a  few  months  ago.  This  was  shortly  fol- 
lowed by  pain  in  the  right  ovarian  region,  irregular  hemorrhages,  of- 
fensive discharge,  and  fever.  Thus  the  history  simulated  one  of  septic 
abortion.  The  cervix  was  the  seat  of  a  soft,  friable  mass,  which  bled 
easily.  The  fundus  and  adnexa  were  normal.  A  provisional  diagnosis 
of  carcinoma  was  made,  biopsy  performed,  and  tuberculosis  reported. 
The  lungs  were  involved,  and  for  this  reason  curettage  and  the  applica- 
tion of  zinc  chlorid  were  decided  upon. 

Yineberg.57  Case  1.  Nonipara,  aged  37.  Regular  and  painful 
menstruation.  Family  history  negative.  Two  and  a  half  years  ago 
suffered  from  a  pleurisy  with  effusion,  otherwise  well.  For  last  three 
weeks,  pain  in  lower  abdomen  and  fever,  amenorrhea  for  two  months, 
and  had  lost  flesh  and  strength.  Cervix  hypertrophied  and  presented 
three  ulcers.  These  were  irregular  in  outline,  moderately  deep,  and 
covered  with  a  dirty  grayish  exudate.  The  remainder  of  the  portio 
was  reddened.  There  was  no  marked  induration,  no  friability  of  the 
tissues,  and  no  tendency  to  bleed  when  slightly  traumatized.  Tuber- 
culosis of  the  body  of  the  uterus  and  adnexa  was  present.  Hysterec- 
tomy was  followed  by  death.     No  autopsy.     Histologic  verification. 

Case  2.  Single  woman,  aged  25  years.  Suffered  from  amenorrhea. 
Rather  profuse  leukorrhea  and  occasional  attacks  of  pain  in  the  right 
groin  for  two  years.  Her  general  health  was  good,  and  there  was  a 
good  family  history.     Hymen  was  intact.     Uterus  small  and  anteflexed. 


TUBERCULOSIS  OF  THE  CERVIX  163 

Cervix  was  soft  and  bled  slightly  to  touch.  Inspection  showed  the 
portio  to  be  covered  with  vascular  granulations.  Case  resembled  a 
marked  endocervicitis.  Attached  to  the  right  wall  of  the  cervical  canal 
was  a  small  cyst,  the  size  of  a  cherry.  This  contained  sebaceous  ma- 
terial. This  was  not  examined  histologically.  Trachelectomy  and 
dilatation  and  curettage.  Adnexa  normal.  Histologic  examination  of 
the  amputated  cervix  verified  the  diagnosis.  Vineberg  considers  this 
a  primary  case;  at  least  no  other  focus  of  tuberculosis  is  referred  to. 

Martin.27  Patient,  aged  25  years,  was  married  and  nullipara.  She 
had  amenorrhea,  leukorrhea,  and  pains  in  the  lower  abdomen  and  back. 
On  histological  examination,  pieces  of  tissue  from  the  cervix  showed 
that  the  process  was  tuberculous  and  not  cancerous. 

Lorrain  and  Chaton.58  Patient,  aged  37  years,  was  married  but  had 
no  children.  She  had  prolapse  of  the  uterus,  hypertrophic  elongation 
of  the  cervix,  and  bilateral  inguinal  adenitis.  The  cervical  tissue  was 
incised  and  tuberculous  products  removed  by  the  curet.  The  histologic 
examination  showed  typical  tuberculosis,  but  no  tubercle  bacilli  could 
be  demonstrated  by  staining.  Injection  of  some  of  the  material  into  a 
guinea  pig  was  followed  by  tuberculosis  in  the  animal. 

Horrocks.59  Woman,  aged  34  years,  who  had  pulmonary  phthisis. 
The  cervix  was  dotted  over  with  grayish,  opaque  vesicles,  with  a  red, 
pulpy  substance  between,  which  bled  easily  when  touched,  and  resem- 
bled a  malignant  neoplasm.  The  ulcer  felt  rather  soft.  Hysterectomy 
showed  the  genital  condition  was  limited  to  the  cervix.  A  uterus  sep- 
tus was  present.  The  patient  made  an  uneventful  recovery,  and  was 
discharged  from  the  hospital  cured.  The  diagnosis  of  tuberculosis  was 
made  on  microscopic  examination. 

Garkisch.'60  Woman,  aged  28  years,  married  but  had  had  no  chil- 
dren or  miscarriages.  She  never  menstruated.  At  external  os  was  a 
polypoid  projection.  Biopsy  was  performed.  Microscopic  examination 
of  tissue  removed  for  diagnosis  showed  typical  tubercles  and  giant  cells. 
Hysterectomy  was  performed,  and  the  corpus  uteri  and  tubes  were  found 
to  be  involved.  In  spite  of  the  fact  that  the  woman  presented  no  other 
evidence  of  tuberculosis,  even  on  a  careful  examination,  and  the  fact 
that  her  husband  was  healthy,  the  author  hesitates  to  regard  the  case  as 
primary.     Normal  convalescence. 

Zweigbaum.15  Tuberculosis  developed,  apparently  primarily,  in  the 
cervix,  then  vagina,  and  then  left  labium  minus,  on  which  there  was  a 
large  ulcer.  These  were  cauterized  and  apparently  cured.  She  died 
later,  however,  from  a  general  tuberculosis,  so  that  it  would  seem  at 
least  likely  that  this  was  not  a  primary  case  of  cervical  tuberculosis,  but 


164        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

one  in  which  the  primary  focus  was  for  a  time  latent.  The  cervical 
lesion  was  of  the  miliary  variety. 

Emanuel.46  A  woman,  aged  50  years,  presented  herself,  suffering 
from  profuse  purulent,  often  blood  streaked  leukorrhea.  The  cervix  was 
found  to  be  enlarged  to  the  size  of  an  apple.  The  enlargement  was  due 
chiefly  to  a  vegetative  outgrowth.  Deep  necrotic  ulcerations  were  also 
present.  Some  of  the  ulcers  involved  the  vagina.  The  body  of  the 
uterus  was  also  enlarged,  and  the  endometrial  cavity  filled  with  caseous 
material.  The  adnexa  were  normal.  A  panhysterectomy  was  per- 
formed. The  patient  died,  and  autopsy  showed  that  miliary  tubercu- 
losis was  present  in  the  liver,  spleen,  and  peritoneum.  The  lungs  were 
normal.  Examination  of  the  cervix  showed  the  usual  histologic  picture 
of  this  condition. 

Frankel.16  Woman  who  died  of  Pott's  disease.  The  mucosa  of  the 
cervix  was  covered  with  fungus-like  masses.  The  vagina  and  body  of 
the  uterus  were  normal,  but  advanced  tuberculous  lesions  of  the  tubes 
were  present.     The  diagnosis  was  confirmed  by  histologic  examination. 

Broye.24  This  patient  was  married,  and  24  years  of  age.  Three 
months  after  a  miscarriage  she  developed  a  tuberculous  peritonitis,  sal- 
pingitis, and  oophoritis.  The  cervix  was  the  seat  of  a  papilloma-like 
outgrowth,  which,  upon  histologic  examination,  presented  the  usual  ap- 
pearance of  tuberculosis  in  this  locality.  A  tuberculous  endometritis 
was  also  present,  an  interesting  point  being  that  the  histologic  changes 
were  most  marked  at  the  placental  site. 

Rigal.25  Patient  had  a  miscarriage  at  the  sixth  month  and  died 
shortly  afterwards.  She  had  general  miliary  tuberculosis  of  the  lungs, 
peritoneum,  and  meninges.  The  cervix  uteri  was  the  seat  of  an  ex- 
tensive ulcerative  lesion,  which  had  involved  the  adjacent  vagina  by 
direct  extension.  The  edges  of  the  ulcer  were  raised,  edematous,  and 
partially  undermined.  The  diagnosis  was  based  upon  histologic  evi- 
dence. Death  and  autopsy  showed  miliary  tuberculosis  of  the  lungs, 
peritoneal  cavity,  meninges. 

Klobb.9  The  specimen  was  discovered  accidentally  at  autopsy  in  a 
woman  who  had  died  of  an  intercurrent  disease.  The  lesion  was  almost 
the  size  of  a  cherry,  and  had  its  origin  low  down  in  the  cervical  canal. 
The  character  of  the  pathologic  process  was  determined  only  upon  his- 
tologic examination.  A  careful  examination  of  the  body  at  the  post- 
mortem failed  to  show  any  other  foci  of  tuberculosis  present. 

Kaufmann.10  Patient,  aged  72  years.  The  external  os  was  small, 
but  the  supravaginal  portion  of  the  cervix  was  notably  thickened  and 
enlarged.     A  section  from  this  portion  showed  it  to  contain  a  cavity 


TUBERCULOSIS  OF  THE  CERVIX  165 

lined  with  semitranslucent  grayish  granulations.  The  walls  were  dis- 
tinctly firm  to  the  touch.  The  mucosa  of  the  cervical  canal  presented 
no  marked  alterations.  On  histologic  examination  tubercles,  giant  cells, 
and  other  evidences  of  this  type  of  infection  were  observed.  Tubercle 
bacilli  were  demonstrated  by  staining. 

Michales.11  Patient,  aged  33  years,  was  married  and  a  nullipara. 
Her  mother  had  died  of  tuberculosis.  The  patient's  lungs  were  normal. 
A  moderate  amount  of  purulent  discharge  was  the  only  marked  symptom 
referable  to  the  cervix.  A  moderate  sized  necrotic  ulcer  of  the  cervix 
was  present,  which  was  cured  by  excision.  A  tuberculous  ulcer  and 
granular  hypertrophy  of  the  adjacent  mucosa  was  diagnosed  histo- 
logically. 

Brouha.8  A  quintipara,  aged  41  years,  with  a  family  history  of 
tuberculosis.  The  last  child  was  born  fourteen  years  ago,  at  which 
time  she  suffered  from  a  pelvic  peritonitis  and  pleurisy.  A  curettement 
has  recently  been  performed.  Now  complains  of  pain  in  the  back 
and  left  iliac  region.  Constipation  and  leukorrhea.  The  anterior  cer- 
vical lip  was  enlarged  and  reddened.  Opening  into  the  cervical  canal, 
and  evidently  interstitial  in  origin,  is  an  ulcer,  the  cavity  of  which  is  red 
and  has  a  worm-eaten  appearance.  On  biopsy  histologic  evidence  of 
tuberculosis  was  discovered.  The  lungs  were  normal  and  no  extra- 
genital foci  of  tuberculosis  were  found.  Chronic  pelvic  inflammatory 
disease  was  present.  Panhysterectomy  and  bilateral  salpingo-oophorec- 
tomy  were  performed.  Although  evidence  of  inflammation  in  the  upper 
genital  tract  was  present,  no  tuberculosis  was  demonstrated.  The  au- 
thor believes  the  condition  to  have  been  contracted  by  direct  infection 
through  coitus.  Brooks 12  reported  the  following  year  that  the  pa- 
tient was  in  good  health. 

Ferrari.13  Case  1.  Patient,  aged  30  years.  She  was  a  nullipara 
and  had  a  tuberculous  ulceration  of  both  cervical  lips.  Polypoid  ex- 
crescences were  also  present.  Microscopic  examination  showed  tuber- 
culosis. Vaginal  hysterectomy  was  performed.  The  convalescence  was 
normal  and  the  patient  was  discharged  from  the  hospital  cured.  No 
other  foci  of  tuberculosis  were  demonstrated  elsewhere  in  the  body. 

Case  2.  The  patient  was  a  multipara,  who  presented  papillary  and 
nodular  excrescences  on  the  cervix.  She  had  had  irregular  menstrua- 
tion and  discharge.  A  trachelectomy  was  performed  and  the  diag- 
nosis verified  by  histologic  examination. 

Giglio.34  Patient  was  28  years  of  age.  The  chief  symptom  was  a 
profuse  purulent  and  at  times  blood  streaked  leukorrhea.  Examination 
showed  the  cervix  to  be  the  seat  of  a  papillary  outgrowth.     A  number 


166        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

of  ragged,  irregular  ulcers  were  also  present.  A  diagnosis  of  sarcoma 
of  the  cervix  was  made.  Vaginal  hysterectomy  was  performed.  Death 
occurred  three  months  later  from  "poussee  de  granulie."  Histologic  ex- 
amination revealed  the  true  character  of  the  cervical  lesion.  Tubercle 
bacilli  were  demonstrated  by  staining  in  the  tissue. 

Glockner.22  Patient,  20  years  of  age.  She  had  a  papillary  tuber- 
culosis of  the  cervix,  resembling  cancer.  The  husband  had  tuberculosis 
of  the  right  testicle  and  epididymis.  The  author  believes  the  infection 
resulted  from  coitus.  A  vaginal  hysterectomy  was  performed,  and  re- 
sulted in  a  cure.    The  diagnosis  was  made  by  histologic  examination. 

Zweifel.61  Patient,  28  years  of  age,  had  a  family  history  of  tuber- 
culosis. A  ragged,  irregular,  necrotic  ulcer  of  the  cervix  was  present 
and  diagnosed  cancer.  The  ulcer  extended  upward  and  involved  the 
endometrial  cavity.  A  panhysterectomy  was  performed.  Histologic 
examination  showed  the  lesions  to  be  tuberculous. 

Mosler.7  The  patient  was  a  child  3  years  of  age,  in  whom  the 
cervix,  uterus,  tubes,  lungs,  peritoneum,  and  intestines  were  all  invaded 
with  tuberculosis.  Death.  Autopsy.  Diagnosis  was  confirmed  by  a 
histologic  examination. 

Hamolle.62  Patient,  aged  57  years,  had  pulmonary  and  peritoneal 
tuberculosis,  from  which  she  died.  The  disease  manifested  itself  in  the 
cervix  and  vagina  as  small  deep  ulcerations  and  here  and  there  papillary 
masses. 

Bender.63  Aged  32  years.  Good  health  until  the  present  illness, 
always  fond  of  sports.  Married.  One  child;  labor  normal.  Miscar- 
riage one  year  ago.  Trouble  dates  from  miscarriage.  Considerable 
hemorrhage  was  present  for  a  time  after  the  miscarriage.  This  finally 
ceased  for  a  time  but  recurred,  and  was  accompanied  by  purulent  leukor- 
rhea.  Examination  of  the  cervix  showed  it  to  be  the  seat  of  an  elliptical 
ulceration.  The  tuberculous  character  of  the  cervical  lesion  was  not 
recognized  until  after  curettage  of  the  uterus  and  amputation  of  the 
cervix.  Histologic  examination  of  the  excised  portions  showed  tuber- 
culosis. Tubercle  bacilli  were  demonstrated  by  staining  methods.  Re- 
covery after  the  operation  was  normal.  Apparently  no  tuberculosis  of 
the  other  sexual  organs  or  other  portions  of  the  body  was  present. 
The  patient's  husband  had  died  of  typhoid  fever,  and  had  always  been 
healthy.      Primary  case. 

Peham/34  This  patient  was  a  nullipara  30  years  of  age.  The  chief 
symptom  was  progressively  increasing  purulent,  and  at  times  blood 
streaked,  leukorrhea.  Examination  showed  that  the  anterior  cervical 
lip  was  the  seat  of  an  ulcerative  lesion,  which  was  suggestive  of  carci- 


TUBERCULOSIS  OF  THE  CERVIX  167 

noma.     A  piece  of  the  ulcer  was  excised  for  microscopic  examination, 
which  revealed  its  true  character.     Tubercle  bacilli  were  demonstrated. 

In  the  discussion  of  Peham's  case,  Fabricius  stated  that  he  had  three 
cases  of  tuberculosis  of  the  cervix. 

Case  1.  A  young  girl  who  had  introduced  a  hair  pin  into  the 
rectum.  This  perforated  the  rectovaginal  septum  and  punctured  the 
cervix.  At  the  point  of  puncture  on  the  cervix  a  tuberculosis  developed. 
The  diagnosis  was  confirmed  by  histologic  examination.  The  girl  died 
nine  months  later  of  tuberculous  meningitis. 

Case  2.  The  patient  was  a  middle  aged  corpulent  woman,  who  pre- 
sented herself,  suffering  from  profuse  purulent,  and  at  times  blood 
stained,  leukorrhea.  Examination  showed  the  cervix  to  be  the  seat  of 
a  necrotic,  sloughing  tumor-like  mass,  which  was  thought  to  be  a  carci- 
noma. Histologic  examination  of  the  tissue,  however,  proved  the  con- 
dition to  be  tuberculosis. 

Case  3.  The  cervix  in  this  case  was  found  to  be  enlarged,  indu- 
rated, and  extremely  hard.  Histologically  the  condition  was  found  to 
be  tuberculosis.  Details  of  this  case  are  not  given.  It  is  of  interest 
chiefly  on  account  of  the  hardness  of  the  lesion. 

Santi.65  This  patient  was  23  years  of  age,  married,  and  had  two 
children.  The  previous  history  showed  that  she  had  suffered  from 
pleurisy  some  time  prior  to  her  present  illness.  She  had  also  been  op- 
erated upon  for  a  peritonitis,  probably  of  tuberculous  origin.  For  some 
time  there  had  been  symptoms  of  Pott's  disease.  The  only  symptoms 
referable  to  the  cervix  were  discharge  and  occasional  irregular  bleed- 
ing. Examination  of  the  cervix  showed  it  to  be  the  seat  of  an  irregu- 
lar growth.  Trachelectomy  was  performed  and  the  tuberculous  char- 
acter of  the  lesion  verified  by  histologic  examination,  the  microscope  re- 
vealing chronic  inflammatory  changes,  numerous  tubercles,  many  of 
which  contained  giant  cells,  and  the  usual  typical  appearance  of  tuber- 
culosis in  this  locality.  One  histologic  peculiarity  was  that,  at  some 
points,  the  squamous  epithelium  over  the  papilla  had  formed  into  masses 
more  or  less  suggestive  of  syncytial  cells.  No  tubercle  bacilli  were 
demonstrated. 

Kromer.20  A  case  of  cervical  tuberculosis,  the  only  other  focus  of 
the  disease  being  a  patch  of  lupus  on  the  left  buttock.  In  this  instance 
the  chief  seat  of  the  disease  was  the  external  03,  but  there  were  tubercles 
in  the  serosa  and  muscularis  of  the  tubes  and  uterus.  She  had  had 
tuberculous  peritonitis  some  years  previously. 

Deletrez.66  The  patient,  aged  21  years.  A  cauliflower  growth  was 
present  on  the  portio,  which  caused  a  suspicion  of  carcinoma,  but  the 


1 68        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

microscope  proved  it  to  be  tuberculous.  The  body  of  the  uterus  pre- 
sented numerous  small  granulations  separate  from  one  another.  Toward 
the  cervix  these  became  papillary  in  character.  The  mucosa  here  was 
reddened.  The  diagnosis  was  confirmed  by  histologic  examination. 
The  patient  was  in  excellent  health  six  months  after  a  total  vaginal 
hvsterectomv.  The  author  believes  this  to  be  a  primary  case.  He  calls 
attention  to  the  fact  that  the  ulcerative  and  miliary  forms  are  usually 
secondary,  but  all  recorded  cases  of  primary  lesions  were  of  the  hyper- 
trophic variety.* 

Everling.67  Patient,  aged  25,  had  apparently  primary  tuberculosis 
of  the  portio.  The  villous  or  papillary  appearance  and  friable  char- 
acter, discharges,  and  irregular  bleeding  suggested  carcinoma  and  pan- 
hysterectomy, but  biopsy  showed  the  real  condition  and  a  high  trachelec- 
tomy  was  considered  sufficient.     Recovery. 

Yon  Franque.42  A  negress,  aged  21  years,  had  irregular  menstrua- 
tion. There  was  a  lesion  on  the  cervix,  which  resembled  a  chancroid. 
This  had  not  caused  symptoms  or  discomfort.  Biopsy  showed  tuber- 
culosis. The  uterus  and  adnexa  were  apparently  normal,  therefore  only 
a  trachelectomy  was  performed.  Histologic  examination  of  the  ampu- 
tated cervix  showed  tuberculosis,  but  no  tubercle  bacilli  or  cheesy  de- 
generation. No  tubercle  bacilli  were  demonstrated  in  any  other  part 
of  the  body. 

Lewers.44  This  patient  had  "bronchitis  for  a  number  of  years." 
She  was  a  nullipara,  36  years  of  age,  had  a  slight,  whitish  leukorrhea 
for  years,  metrorrhagia  for  9  months,  and  recently  the  discharge  had 
become  effusive.  Metrorrhagia  usually  occurred  in  the  form  of  "spot- 
ting," following  slight  trauma.  She  had  noticed  pieces  of  "skin"  from 
time  to  time  in  the  blood  stained  intermenstrual  leukorrhea.  The  periods 
were  regular  and  there  was  no  increase  in  duration  or  amount.  The 
cervix  was  more  patulous  than  usual,  and  a  soft  friable  growth  was 
felt  in  the  cervical  canal,  extending  as  far  up  as  the  fingers  could  reach. 
This  bled  easily  on  touch.  The  uterus  was  normal.  A  diagnosis  was 
made  of  carcinoma.  Yaginal  hysterectomy  was  performed.  Recovery. 
The  diagnosis  was  made  by  histologic  examination.  The  patient  was 
well  5  years  after  the  operation.  The  cervical  mucous  membrane  was 
involved  as  well  as  the  portio. 

Croft.68  Patient,  aged  26  years,  had  a  family  history  of  tubercu- 
losis. A  moderate  amount  of  leukorrhea  had  been  present  for  some 
time.  The  menstruation  was  always  irregular.  She  had  amenorrhea 
for  nine  months.     The  cervix  was  enlarged,  softened,  and  friable,  bled 

*  A  careful  study  of  the  literature  fails  to  confirm  this  statement. 


TUBERCULOSIS  OF  THE  CERVIX  169 

easily,  and  there  was  a  profuse  mucopurulent  discharge.  The  cervix  felt 
roughened,  the  anterior  lip  was  elongated,  everted,  and  the  raised  por- 
tion coarsely  papillary,  the  projections  being  of  various  sizes,  some  as 
large  as  a  pea.  The  involvement  was  chiefly  around  the  center  of  the 
portio.  The  uterus  and  adnexa  were  normal.  Biopsy  was  performed 
and  a  diagnosis  of  tuberculosis  was  made.  Hysterectomy.  Recovery. 
Histological  examination  then  showed  involvement  of  the  corporeal 
endometrium  also. 

Cullen.69  Case  1.  Autopsy  specimen.  The  patient  died  of  a  gen- 
eral tuberculosis.  The  uterus  measures  7  cm.  in  length,  4.5  cm.  in 
breadth,  and  4.5  cm.  anteroposteriorly.  In  the  vaginal  fornix  is  an  ulcer 
1.5  cm.  in  diameter  and  1  cm.  in  depth.  This  has  a  sharply  defined 
margin  and  a  smooth  base,  studded  with  minute  yellowish  dots,  varying 
from  a  pin  point  to  1  mm.  in  diameter.  The  cervix  measures  3  cm.  in 
length  and  2.5  cm.  in  diameter.  There  is  a  slight  transverse  laceration. 
The  lips  are  red  and  congested,  but  present  an  intact  surface.  The 
outer  surface  of  the  cervix,  1  cm.  from  the  os  on  both  sides,  presents  a 
raised  appearance,  the  tissue  being  whitish  yellow,  and  showing  an  ir- 
regular, eaten  out  appearance ;  the  ulcers  vary  from  1  to  3  cm.  in  diam- 
eter. On  opening  the  cervix  a  cavity  1.5  cm.  in  diameter  is  found, 
which  begins  at  a  point  1.5  cm.  above  the  external  os.  This  contains 
densely  necrotic  material.  Its  walls  are  ragged,  eaten  out,  and  irregu- 
lar. This  tissue  is  yellowish,  soft,  and  stands  out  in  contrast  to  the 
injected  uterine  wall.  The  adnexa  are  also  involved.  The  diagnosis 
was  confirmed  by  histologic  examination. 

Case  2.  Attempted  vaginal  hysterectomy  for  condylomata  and  tu- 
berculosis of  the  cervix.  The  autopsy  revealed  tuberculosis  of  the  en- 
dometrium, tubes,  and  ovaries.  Miliary  tuberculosis  of  the  lungs  and 
pleura.  Tuberculous  ulcer  of  the  intestines.  Tuberculosis  of  the  spleen 
and  kidneys,  and  solitary  tubercles  in  the  brain.  The  patient,  aged  17 
years,  colored,  had  a  family  history  of  tuberculosis.  Profuse,  effusive 
leukorrhea,  fever,  etc.  No  cough.  The  cervix  and  surrounding  vaginal 
vault  were  occupied  by  firm,  smooth,  polypoid  elevations,  lining  an  ul- 
cerated cavity.  These  were  pinkish  in  color.  Biopsy  was  performed. 
Amputation  of  the  cervix  was  followed  by  quite  severe  hemorrhage. 
Histologic  diagnosis. 

Driessen.70  This  case  occurred  in  a  woman  who  had  been  operated 
upon  seven  years  before  for  a  stricture  of  the  rectum  and  had  complained 
for  some  time  of  menorrhagia  and  mucopurulent  discharge.  The  cervix 
was  found  enlarged  and  studded  with  many  small  ulcers,  most  numerous 
about  the  external  os,  and  growing  fewer  towards  the  periphery.     In  the 


170        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

ad  de  sac  were  small,  red  spots  with  yellowish  centers.  Vaginal  hysterec- 
tomy.   Histologic  examination  showed  characteristic  tuberculous  changes. 

Vitrac.48  This  patient  was  a  woman,  21  years  of  age,  who  entered 
the  service  of  Lannelongue  and  Bordeaux,  complaining  of  pain  in  the 
lower  abdomen  and  of  leukorrhea.  There  was  a  history  of  tuberculosis 
and  examination  showed  lesions  at  the  apex  of  the  left  lung.  There  was 
a  history  of  trauma  of  the  genital  organs,  which  was  followed  by  bleed- 
ing and  dysuria.  The  cervix  was  enlarged  and  the  seat  of  a  vegetative 
outgrowth  about  the  size  of  a  walnut.  This  was  elastic,  yielding  to  the 
touch.  The  surface  of  the  portio  not  involved  in  the  papillomatous 
growths  was  reddened  and  inflamed.  The  uterus  was  small  and  adnexa 
adherent.  Biopsy  was  performed  and  the  diagnosis  of  tuberculosis 
arrived  at.  A  vaginal  hysterectomy  was  performed  and  the  diagnosis 
confirmed  by  further  histologic  examination  and  also  by  animal  inocula- 
tion.    Operative  recovery. 

Frank.23  This  patient  gave  a  previous  history  of  a  tuberculous  bone 
disease,  involving  the  metacarpal  bone  and  one  phalanx  of  the  middle 
finger,  which  was  excised  and  apparently  cured  6  years  ago.  This  patient 
had  never  suffered  any  pain  and  had  sought  relief  for  dysmenorrhea. 
Examination  at  that  time  showed  the  portio  vaginalis  to  be  enlarged  and 
somewhat  mushroom  shaped.  Numerous  vesicles  and  nodules  were 
present,  most  numerous  about  the  external  os.  The  papillary  masses 
bled  readily.  The  case  was  diagnosed  clinically  as  a  malignant  neoplasm. 
Biopsy  showed  the  true  character  of  the  lesion.  Following  the  diagnostic 
excision  there  was  considerable  hemorrhage,  which  required  firm  tam- 
ponage.  Hysterectomy  was  performed ;  the  tubes  were  normal.  Recov- 
ery. Frank  believes  the  infection  in  this  case  resulted  from  contamination 
by  the  hands  or  by  soiled  linen. 

Beyea.14  A  patient,  aged  23  years,  with  a  negative  family  history. 
She  had  irregular  menstruation,  dysmenorrhea,  and  more  or  less  leukor- 
rhea, at  times  purulent,  for  3  years.  The  portio  vaginalis  was  enlarged 
to  twice  its  normal  size  and  was  the  seat  of  an  extensive  ulcer,  which 
involved  the  external  os.  This  ulcer  was  bright  red  and  bled  easily. 
Trachelectomy  and  bilateral  salpingo-oophorectomy  was  performed,  and 
the  diagnosis  made  by  the  microscope.  Tubercle  bacilli  were  demon- 
strated by  staining  methods  in  some  of  the  sections.  A  tuberculous 
salpingitis  was  also  present.  The  patient  was  in  good  health  16  months 
after  the  operation. 

Baudet.71  This  patient  was  51  years  of  age  and  presented  herself, 
exhibiting  symptoms  suggestive  of  carcinoma  of  the  cervix.  Examina- 
tion showed  the  cervix  to  be  the  seat  of  an  extensive  papilla-like  growth, 


TUBERCULOSIS  OF  THE  CERVIX  171 

which  also  involved  the  adjacent  anterior  vaginal  wall.  The  tumor-like 
masses  were  moderately  friable,  and  were  covered  with  a  profuse 
malodorous  discharge.  The  excised  tissue  presented  the  usual  histologic 
picture  of  tuberculosis  in  this  area.  A  careful  examination  of  the  lungs 
failed  to  reveal  any  evidence  of  tuberculosis.  This  was  of  the  type 
described  by  the  French  writers  as  the  pseudoneoplastic.     Primary  case. 

Young.72  This  patient's  family  history  was  negative  for  tuberculosis. 
She  was  a  tripara.  The  last  child  was  born  2^  years  ago.  They  are  all 
healthy.  The  patient  was  healthy  until  six  months  ago,  when  the  periods 
began  to  become  more  profuse  and  of  longer  duration  than  usual,  and 
for  the  last  five  weeks  thick  yellowish  non-odorous  leukorrhea  has  been 
present.  Constant  pain  in  the  lower  abdomen  and  sacral  region  has  been 
present  for  a  similar  period.  There  was  no  enlargement  of  the  inguinal 
glands.  The  cervix  was  indurated  and  greatly  enlarged.  Its  surface 
was  uneven  and  ulcerated  in  places,  and  in  other  places  nodular  and 
papillary,  but  not  friable.  The  uterus  was  freely  movable.  There  was  a 
suspicion  of  malignancy.  Vaginal  hysterectomy  was  performed.  The 
patient  was  examined  six  months  after  operation  and  was  found  healthy. 
The  diagnosis  rests  upon  the  histologic  evidence. 

Nebesky.73  This  patient  was  a  woman  aged  33  years.  A  careful 
examination  failed  to  reveal  any  foci  of  tuberculosis  other  than  those 
in  the  genital  tract.  The  cervix  was  the  seat  of  an  advanced  tuber- 
culosis; the  endometrium  of  the  body  of  the  uterus  and  the  tubes  were 
also  involved,  but  Nebesky  believes  these  were  secondary  to  the  cervical 
lesion,  as  the  pathologic  changes  became  progressively  more  pronounced 
as  the  cervix  was  approached.  The  tubes  were  but  mildly  affected. 
Panhysterectomy  and  bilateral  salpingo-oophorectomy  were  performed 
and  resulted  in  a  cure. 

Matthews.74  This  patient  was  single,  22  years  of  age,  negress,  never 
pregnant.  First  menstruated  at  15  years,  one  day's  duration  and  scant, 
regular.  Later,  every  three  weeks.  Dysmenorrhea  for  three  years,  and 
occasionally  colicky  pains  in  the  hypogastric  region.  Recently  profuse 
mucopurulent  leukorrhea,  and  often  blood  stained,  has  been  present.  Ex- 
amination showed  the  cervix  enlarged  to  twice  its  normal  size,  and  the 
seat  of  a  worm-eaten  bleeding  ulcer.  The  right  adnexa  were  enlarged, 
adherent,  and  the  base  of  the  broad  ligament  was  thickened.  The  fundus 
was  enlarged  and  partially  adherent.  A  vaginal  hysterectomv,  bilateral 
salpingo-oophorectomy  and  excision  of  the  upper  portion  of  the  vagina 
were  performed.  The  patient  was  discharged  from  the  hospital  as  cured. 
Histologic  examination  showed  the  cervix  to  be  the  seat  of  a  diffuse 
tuberculosis,  numerous  typical  tubercles,  many  of  them  cheesy,  being 


172        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

found.  No  record  was  made  of  the  demonstration  of  tubercle  bacilli 
nor  was  the  vaginal  lesion  reported  upon,  but  it  was  evidently  a  direct 
extension  from  the  cervix. 

Buscarlet.75  26  years  of  age.  Family  history  of  tuberculosis.  Pul- 
monary tuberculosis  was  present.  Complained  of  pain  in  the  vagina 
and  a  profuse,  thick,  foul  leukorrhea.  Examination  showed  the  cervix 
the  seat  of  a  friable  granular  growth,  and  covered  with  mucopurulent 
discharge.  Death  occurred  from  the  pulmonary  lesions.  Autopsy 
showed  tuberculosis  also  present  in  the  tubes,  ovaries,  and  body  of  the 
uterus. 

Chaton.4  Family  history  of  tuberculosis.  Entered  the  Saint  Joseph 
Hospital  with  a  diagnosis  of  uterine  prolapse.  The  cervix  was  hyper- 
trophied.  The  suspected  area  was  friable  and  ulcerated  and  whitish  on 
section,  and  here  and  there  caseous  areas  were  present.  The  adnexa 
were  involved.  Diagnosis  confirmed  by  histologic  and  inoculation 
methods.  The  lesion  evidently  began  as  an  interstitial  cervical  tuber- 
culosis. 

Galabrin.76  The  author  merely  mentions  during  the  course  of  a 
discussion  a  case  of  tuberculosis  of  the  cervix,  which  was  mistaken  for 
carcinoma.  The  correct  etiology  of  the  condition  was  discovered  only 
upon  histologic  examination. 

Bouilly.41  The  patient  was  26  years  of  age  and  gave  a  family  history 
of  tuberculosis.  Suffered  a  cervical  laceration  during  delivery.  On  the 
posterior  cervical  lip,  at  the  seat  of  the  laceration,  slowly  developing  ulcer 
appeared.  This  was  excised,  resulting  in  recovery.  The  ultimate  out- 
come of  the  case  is  not  stated.  The  diagnosis  is  founded  upon  histologic 
examination. 

Bouffe.52  The  patient  was  26  years  of  age,  and  gave  a  family  history 
of  tuberculosis.  Married  and  her  husband  had  suffered  from  a  tuber- 
culous epididymis.  She  complained  of  pain  in  the  vagina  and  purulent 
leukorrhea.  Examination  revealed  an  ulcer  occupying  the  posterior 
cervical  lip,  the  base  and  edges  of  which  were  moderately  firm  and 
presented  a  somewhat  cicatricial  appearance.  Palliative  treatment  was 
followed  by  improvement.  Tubercle  bacilli  were  demonstrated  from 
the  ulcer. 

Reverdin.77  Case  1.  The  patient  was  30  years  of  age  and  presented  a 
personal  and  family  history  of  tuberculosis.  For  three  months  had  been 
suffering  from  irregular  and  moderately  profuse  hemorrhages,  chiefly 
metrorrhagic  in  type.  Examination  showed  an  ulcer  on  the  vaginal 
cervix,  and  the  body  of  the  uterus  and  adnexa  also  involved.  On  account 
of  the  extensive  primary  involvement  and  the  poor  general  condition  of 


TUBERCULOSIS  OF  THE  CERVIX  173 

the  woman,  no  radical  treatment  was  employed.  Death  occurred  in  3 
months. 

Case  2.  This  patient  was  23  years  of  age  and  gave  a  family  history 
of  tuberculosis.  Pulmonary  tuberculosis  was  present.  For  some  time 
the  patient  had  suffered  from  pain  in  the  lower  abdomen  and  metror- 
rhagia. The  cervix  was  enlarged,  and  on  the  anterior  lip  was  a  reddened 
ulceration.  This  was  treated  with  silver  nitrate  and  tincture  of  iodin, 
and  is  said  to  have  disappeared.  The  body  of  the  uterus  was  also 
enlarged  and  probably  involved  in  the  tuberculous  process. 

Nanard.43  Pulmonary  and  intestinal  tuberculosis  was  present. 
Death  occurred.  At  autopsy  the  anterior  cervical  lip  was  found  to  be 
the  seat  of  an  extensive  ulcer,  which  involved  the  external  os.  The  tubes 
and  uterus  were  diseased.  The  diagnosis  was  confirmed  by  histologic 
examination. 

Lepitit.18  This  was  an  autopsy  specimen,  the  subject  having  died  of 
a  tuberculous  peritonitis  and  other  complications,  the  lungs  also  being 
involved.  The  cervix  was  the  seat  of  an  ulcer,  which  possessed  irregular 
edges  and  a  necrotic  base.  The  diagnosis  was  confirmed  by  his- 
tologic examination.  The  fallopian  tubes  and  uterus  were  also  in- 
volved. 

Cornil.50,  89  Case  1.  The  patient  presented  an  ulcer  on  the  cervix. 
On  histologic  examination  this  was  found  to  contain  tubercles  and  giant 
cells  and  other  evidence  of  tuberculosis.  This  is  one  of  the  earliest  if 
not  the  earliest  case  verified  by  histologic  examination. 

Case  2.  This  patient  was  a  middle  aged  woman,  whose  chief  symp- 
toms were  discharge  and  irregular  bleeding.  Examination  showed  the 
cervix  increased  in  size  and  indurated;  numerous  vegetative  outgrowths 
were  present.  The  diagnosis,  sarcoma  of  the  cervix,  was  made,  and  a 
panhysterectomy  performed.  The  correct  diagnosis  was  arrived  at  by 
histologic  examination. 

Uhland.78  This  patient  was  20  years  of  age  and  presented  a  family 
history  of  tuberculosis.  The  symptoms  referrable  to  the  cervical  con- 
dition were  leukorrhea  and  irregular  bleeding  of  the  metrorrhagic  type. 
Death  occurred  from  a  tuberculous  peritonitis.  Autopsy  showed  the 
cervix  to  be  the  seat  of  a  tuberculosis;  the  corporeal  endometrium  and 
myometrium  and  adnexa  were  also  involved. 

Laboulbene.79  A  patient,  20  odd  years  of  age,  died  of  pulmonary 
tuberculosis.  At  autopsy  the  cervix  was  found  to  be  the  seat  of  an 
irregular  ulcer. 

Parrot.80  The  patient  was  an  infant  that  had  suffered  from  a  gen- 
eral tuberculosis,  pulmonary,  intestinal,  meningeal,  renal,  etc.    The  cervix 


174        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

was  the  seat  of  numerous  small  outgrowths  which  also  involved  the 
adjacent  vagina. 

Reclus.81  The  patient  was  about  30  years  of  age.  She  was  pale  and 
anemic.  There  was  a  fistula  in  ano,  probably  tuberculous  in  origin, 
present.  The  cervix  was  enlarged  and  the  seat  of  numerous  small  semi- 
transparent  granulation-like  outgrowths.  The  lesions  were  small  and 
superficial  and  were  treated  by  cauterization  with  the  actual  cautery  and 
the  application  of  the  tincture  of  iodin.     Recover)7. 

Pollosson  and  Violet.40  This  patient  was  45  years  of  age  and  gave 
a  family  history  of  tuberculosis.  Pulmonary  tuberculosis  was  present. 
The  cervix  was  the  seat  of  a  lesion  which  resembled  carcinoma,  involving 
chiefly  the  anterior  lip.  A  vagino-abdominal  hysterectomy  was  per- 
formed, and  upon  histologic  examination  of  the  cervix  the  true  character 
of  the  condition  was  discovered.  Adnexal  lesions  were  also  present. 
Operative  recovery. 

Raynaud.1  Case  1.  Death  from  pulmonary  tuberculosis.  Autopsy 
showed  a  small  tumor  springing  from  the  posterior  cervical  lip.  A 
doubtful  case. 

Case  2.  The  patient  was  37  years  of  age  and  suffered  from  pul- 
monary and  meningeal  tuberculosis.  There  was  a  moderate  sized  necrotic 
ulcer  on  the  portio.  Vaginitis  and  adnexal  lesions  were  present.  The 
case  is  without  histologic  or  bacteriologic  verification. 

Haby.82  The  patient  was  21  years  of  age  and  had  always  been  deli- 
cate. No  pulmonary  lesions  were  present.  Profuse  offensive  leukorrhea 
was  present.  A  speculum  introduced  into  the  vagina  showed  the  cervix 
to  be  the  seat  of  a  papillomatous,  friable,  easily  bleeding,  tumor-like  out- 
growth, covered  with  a  glairy  discharge,  which  was  clinically  diagnosed 
as  a  sarcoma.  Biopsy  and  curettage,  however,  showed  the  true  nature 
of  the  lesion.    Tubercle  bacilli  were  demonstrated. 

Hofbauer.49  The  patient  was  26  years  of  age  and  presented  a  family 
history  of  tuberculosis.  She  was  a  multipara  and  the  labors  had  been 
normal.  The  lungs  and  heart  were  normal.  Springing  from  the  cervix 
was  a  tumor-like  outgrowth.  A  diagnosis  of  a  cervical  neoplasm  was 
made  and  a  vaginal  hysterectomy  performed.  Histologic  examination 
showed,  however,  that  the  uterus  and  cervix  were  the  seat  of  a  tuber- 
culosis. 

Thiercelin.26  The  patient  was  24  years  of  age  and  gave  a  negative 
family  history  of  tuberculosis.  The  chief  symptoms  referable  to  the 
genital  tract  were  menorrhagia  and  discharge.  The  temperature  was 
40 °  C,  and  there  was  pain  in  the  lower  abdomen.  Death  resulted  from 
advanced  pulmonary  tuberculosis,   involvements  of  the   fallopian  tubes, 


TUBERCULOSIS  OF  THE  CERVIX  175 

pericardium,  lungs,  and  body  of  the  uterus.  The  cervix  was  the  seat  of 
a  deep  ulcer,  the  walls  of  which  were  soft,  spongy  and  friable.  The 
lesions  had  apparently  extended  from  the  external  os.  The  adjacent 
vagina  was  also  involved.  The  diagnosis  was  verified  by  histologic 
examination.  The  disease  followed  a  miscarriage,  and  the  pulmonary 
symptoms  developed  subsequently. 

Meyer.33  The  patient  was  30  years  of  age  and  had  suffered  from 
lupus.  Metrorrhagia  and  leukorrhea  were  the  chief  symptoms  referable 
to  the  genital  tract.  Examination  showed  that  the  cervix  was  consider- 
ably enlarged,  reddened  and  indurated.  A  portion  of  the  suspected  tissue 
examined  histologically  showed  giant  cells  and  other  evidences  of 
tuberculosis. 

Godard.83  The  patient  was  23  years  of  age  and  was  admitted  to  the 
service  of  Louis  at  the  Hotel  Dieu,  where  she  died  of  a  wide  spread 
tuberculosis,  the  meninges,  lungs,  intestines,  and  other  organs  being 
involved.  It  had  been  noticed  before  death  that  the  cervix  was  reddened; 
it  was  subsequently  found  to  be  the  seat  of  a  caseous  ulcer.  Histologic 
examination  by  Corvisart. 

Cotte.36  The  patient  was  an  anemic  woman  23  years  of  age.  The 
family  history  was  negative  for  tuberculosis.  There  had  been  irregular 
bleeding  and  discharge  for  some  months.  The  cervix  was  enlarged,  and, 
surrounding  the  os,  was  an  area  somewhat  resembling  eversion.  The 
adnexa  were  also  involved,  but  the  uterus  was  small  and  sclerotic.  His- 
tologic examination  of  the  suspected  cervical  lesion  showed  this  to  be  a 
tuberculous  ulceration. 

Schutt.32  The  patient  died  when  33  years  of  age  of  a  general  tuber- 
culosis. An  early  pregnancy  was  found,  and  the  decidua  and  even,  in 
some  areas,  the  myometrium,  was  the  seat  of  caseous  lesions.  The 
cervical  mucosa  was  also  involved.  It  was  in  some  areas  thickened  and 
reddened  and,  on  histologic  examination,  evidence  of  a  tuberculous 
cervicitis  was  found.  Schutt  states  that  the  inflammation  of  the  cervix 
was  catarrhal  in  type.  The  surface  and  granular  epithelium  presented 
characteristic  changes,  caseation  in  or  near  the  gland,  and  tubercle  bacilli. 

Sippel.35  The  patient  was  31  years  of  age  and  complained  of  leukor- 
rhea and  irregular  bleeding.  On  inspection,  the  cervix  was  found  to  be 
reddened  and  congested  and  to  be  the  seat  of  an  ulcer,  the  edges  of 
which  were  firm  to  the  touch.  Biopsy  was  performed  and  a  typical 
histologic  picture  of  tuberculosis  found.  The  lungs  and  fallopian  tubes 
were  also  tuberculous. 

Menetrier.28  The  patient  was  24  years  of  age  and  died  of  pulmon- 
ary tuberculosis  under  the  care  of  Jaccound.     The  body  of  the  uterus 


176        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

was  enlarged.  The  cervix  was  the  seat  of  an  extensive  ulceration,  the 
surface  of  which  was  vascular  and  friable.  Considerable  caseous 
material  was  present.  Tubercle  bacilli  were  demonstrated.  The  fallopian 
tubes  were  also  involved. 

Mayor.84  This  was  a  patient  suffering  from  pulmonary  tuberculosis 
in  the  service  of  Sireday.  A  whitish,  granular  ulceration  was  present  on 
the  anterior  lip  of  the  cervix.  A  pelvic  peritonitis,  involving  the  uterus 
and  appendages,  was  also  present.  Death  occurred  and  an  autopsy  was 
performed.  Verification  of  the  etiology  of  the  cervical  lesions  was 
obtained  by  histologic  examination. 

Adenot.85  The  patient  was  17  years  of  age  and  admitted  to  the 
service  of  Poncet  suffering  from  tuberculous  peritonitis.  A  laparotomy 
was  performed  and  was  followed  by  death.  At  autopsy  the  lungs  were 
found  to  be  involved.  The  mucosa  of  the  cervix  was  reddened  and  a 
small  lenticular  shaped  ulcer  was  present.  Histologic  verification  of  the 
diagnosis  was  made. 

Boldt.86  The  patient  had  a  tuberculous  pleurisy  and  an  ulceration 
upon  the  cervix.  A  curettage  was  performed  and  later  a  panhysterec- 
tomy. Death  occurred  six  hours  later.  Histologic  verification  of  the 
diagnosis. 

Cheron.87  The  patient  was  24  years  of  age,  and  entered  the 
Saint-Lazare  hospital  suffering  from  pulmonary  tuberculosis.  An  ulcer 
was  found  in  the  cervix,  which  somewhat  resembled  an  ectropion.  This 
was  chronic  looking  in  appearance,  and  gave  no  marked  symptoms. 

Chiarabba.88  Menstruated  at  16  years.  At  24  years  the  menstruation 
disappeared.  The  chief  local  symptom  was  discharge.  The  body  of  the 
uterus  was  enlarged  and  the  cervix  was  the  seat  of  an  ulcer,  the  base  of 
which  was  granular  in  appearance.  The  diagnosis  was  verified  by  his- 
tologic examination.  The  patient  also  had  a  tuberculous  peritonitis  and 
involvement  of  the  uterus,  tubes,  and  labia  majora  and  minora. 

Fernet.90  This  patient  was  27  years  of  age  and  suffered  from  pul- 
monary tuberculosis.  The  cervix  was  the  seat  of  a  small  granular 
erosion,  which  under  local  treatment  disappeared.  Tubercle  bacilli  were 
demonstrated  in  the  vaginal  discharge.     A  doubtful  case. 

Frerichs.91  The  patient  was  25  years  of  age  and  presented  an 
ulceration  on  the  mucosa  of  the  cervix,  which  extended  some  distance 
into  the  canal.  The  fallopian  tubes,  uterus  and  pericardium  were  involved 
and  also  the  kidney,  intestines  and  other  areas. 

Gummert.92  The  patient  was  a  nullipara,  29  years  of  age,  who  suf- 
fered from  a  purulent  leukorrhea  and  amenorrhea.  There  was  a  circular 
ulcer  at  the  external  os,  and  on  the  surface  of  the  portio  were  numerous 


TUBERCULOSIS  OF  THE  CERVIX  177 

small,  whitish  elevations  about  the  size  of  millet  seeds.  Biopsy  confirmed 
the  diagnosis  of  tuberculosis  and  a  vagino-abdominal  hysterectomy  was 
performed.    Adnexitis  was  present. 

Gottschalk.93  The  patient  was  a  virgin,  32  years  of  age,  who  pre- 
sented a  previous  history  of  tuberculosis.  Pains  in  the  lower  abdomen 
and  a  profuse,  thick,  offensive  discharge  were  present.  Examination 
showed  a  papillary  mass  originating  from  the  cervix.  A  vaginal  hysterec- 
tomy was  performed  with  an  excellent  result.  Tuberculosis  of  the  endo- 
metrium and  tubes  was  present.     Histologic  verification  of  the  diagnosis. 

Haidenthaler.94  The  patient  was  28  years  of  age  and  presented  a 
previous  history  of  tuberculosis.  An  ulcer  was  present  on  the  anterior 
cervical  lip.  This  was  curetted,  without  marked  benefit.  The  patient 
subsequently  died,  and  autopsy  showed  pulmonary  and  renal  tuberculosis 
and  a  tuberculous  salpingitis.  This  diagnosis  of  the  cervical  lesion  was 
verified  by  histologic  examination. 

Holmes.05  The  subject  was  a  cachectic  woman,  who  died  of  a  general 
tuberculosis,  the  lungs,  peritoneum,  intestines,  and  adnexa  being  involved. 
A  miliary  tuberculosis  is  said  to  have  been  present  in  the  cervix.  A 
doubtful  case. 

Knauer.96  The  specimen  was  presented  before  the  Vienna  Medical 
Society.  The  disease  was  of  the  ulcerative  type,  the  vaginal  portion  of 
the  cervix  being  the  seat  of  a  lesion.  A  panhysterectomy  had  been 
performed. 

Liouville.97  The  cervix  was  the  seat  of  a  tuberculous  lesion  and  the 
fallopian  tubes  were  also  involved.  The  case  is  extremely  doubtful, 
despite  the  fact  that  the  diagnosis  was  verified  by  Lebert. 

Rivilliod.98  The  subject  was  an  aged  woman,  who  died  of  pulmon- 
ary and  intestinal  tuberculosis.  The  uterus  and  adnexa  were  the  seat 
of  inflammatory  lesions.     An  ulcer  was  present  in  the  cervix. 

Richelot."  Case  1.  The  patient  suffered  from  pulmonary  tuber- 
culosis. An  ulcer  was  present  in  the  cervix,  and  a  hysterectomy  was 
performed.  The  diagnosis  was  verified  by  histologic  examination.  This 
case  is  not  reported  by  Richelot  in  detail. 

Case  2.  The  patient  was  a  nullipara.  Examination  showed  the 
cervix  enlarged  and  the  seat  of  an  ulcerative  lesion.  Biopsy  was  per- 
formed and  the  diagnosis  of  tuberculosis  made.  Hysterectomy  was  then 
performed,  and  examination  of  the  specimen  thus  obtained  showed  in- 
volvement of  the  cervical  canal.  The  corporeal  endometrium,  according 
to  Cornil,  was  the  seat  of  a  non-tuberculous  endometritis.  He,  however, 
thinks  that  the  cervical  tuberculosis  was  the  result  of  a  hematogenic 
infection. 


i/8        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Yon  Hauschka.100  The  patient  was  at  the  cancer  age  and  presented 
symptoms  suggestive  of  this  condition.  The  cervix  was  enlarged  and 
covered  with  partially  necrotic  papillary  outgrowths,  which  were  bathed 
in  an  offensive  discharge.  A  vaginal  hysterectomy  was  performed  and 
the  diagnosis  arrived  at  by  histologic  examination.  Tuberculosis  was 
also  present  in  the  body  of  the  uterus  and  in  the  fallopian  tubes. 

Schultze.101  The  patient  presented  a  previous  history  of  tuberculosis. 
Leukorrhea  was  the  chief  local  symptom.  The  mucosa  of  the  cervix  was 
irregular,  reddened,  and  bathed  in  an  offensive  discharge.  Biopsy  was 
performed  and  the  diagnosis  of  tuberculosis  made.  Vaginal  hysterectomy 
was  then  performed.  Bacteriologic  and  histologic  examination  confirmed 
the  diagnosis  of  the  cervical  condition. 

Spath.6  The  patient  was  26  years  of  age  and  gave  a  previous  history 
of  tuberculosis.  The  lungs,  the  body  of  the  uterus,  were  involved. 
The  cervix  was  the  seat  of  an  ulcerative  lesion.  The  base  of  the  ulcer 
had  a  granular  appearance. 

Thompson.102  Hypoplasia  of  the  lower  genital  tract  was  present  in  a 
young  girl.  The  cervix  was  the  seat  of  numerous  small  semitranslucent 
elevations  which  were  thought  to  be  miliary  tubercles.  A  pelvic  peri- 
tonitis was  present.  In  this  case  small  retention  cysts  were  probably 
mistaken  for  miliary  tubercles,  as  has  previously  been  done  by  Lis- 
franc  103  and  Thiry.104 

Walther.105  The  patient  was  26  years  of  age.  Amenorrhea  was 
present.  Leukorrhea  had  been  present  for  some  time.  The  body  of  the 
uterus  was  the  seat  of  a  tuberculosis.  There  was  an  ulcer  on  the  cervix, 
which  was  covered  with  glairy  discharge.  The  base  of  the  ulcer  was 
moderately  soft.  Biopsy  was  performed  and  the  diagnosis  of  tuberculosis 
arrived  at. 

Weigert.106  An  aged  woman  suffering  from  pulmonary  and  peri- 
toneal tuberculosis.  An  ulceration  was  present  upon  the  vaginal  cervix 
and  had  extended  to  the  adjacent  vagina.     Clinical  diagnosis  only. 

Winter.107  The  patient  suffered  from  pulmonary  and  peritoneal 
tuberculosis.  A  tuberculous  endometritis  and  salpingitis  was  also  pres- 
ent. There  was  a  necrotic  ulceration  on  the  portio  vaginalis.  The 
histologic  examination  confirmed  the  diagnosis. 

Ducuing  and  Rigaud.108  The  patient  was  33  years  of  age.  She 
entered  the  service  of  Chamayou  at  the  Hotel  Dieu.  Gave  a  previous 
history  of  tuberculosis.  Bipara.  Pulmonary  tuberculosis.  Irregular 
menstruation  and  profuse  purulent  leukorrhea  were  the  chief  symptoms 
referable  to  the  genital  tract.  Examination  shows  the  external  os  to  be 
the  seat  of  an  irregular  ulceration,  affecting  chiefly  the  right  side  of  the 


TUBERCULOSIS  OF  THE  CERVIX  179 

cervix.  The  cervix  was  increased  in  size.  Biopsy  revealed  the  true 
character  of  the  lesion.  Panhysterectomy  was  performed.  Animal 
inoculation  from  the  cervix  produced  tuberculosis.    The  patient  recovered. 

Williams.109  Case  1.  Aged  63  years,  multipara;  death  from  pul- 
monary tuberculosis.  Autopsy  showed  advanced  phthisis  and  tuberculous 
pelvic  peritonitis.  Uterus  slightly  enlarged.  Anterior  cervical  lip  hyper- 
trophied  and  adherent  to  the  adjacent  vaginal  wall.  A  number  of  ulcers 
were  present.  They  were  irregular,  sharply  cut,  possessed  slightly  raised 
edges  and  a  base  studded  with  grayish  semitransparent  granulations. 
Extension  to  the  adjacent  vagina  had  occurred.  The  diagnosis  was 
verified  by  histologic  examination. 

Case  2.  Bipara,  aged  36  years.  Chief  symptoms  backache  and  pro- 
fuse leukorrhea.  These  symptoms  were  of  several  months  standing. 
Painful  and  scanty  menstruation.  The  cervix  was  lacerated  and  felt 
indurated,  and  was  reddened  and  the  seat  of  an  ulcer,  the  base  of  which 
was  yellowish  gray,  with  indurated  and  sharply  cut  edges. 

This  bled  easily  to  touch.  A  caseous  cast  filled  the  ulcer,  which,  when 
removed,  left  a  nodular  bleeding  base.  Histologic  verification  of  diag- 
nosis. Palliative  treatment,  but  patient  still  under  treatment  when  report 
was  made.  Patient  had  some  lung  condition  some  time  prior  to  the 
appearance  of  the  genital  symptoms,  and  was  a  delicate  woman. 

Maly.110  The  patient  was  a  single  woman,  21  years  of  age.  Pul- 
monary tuberculosis  had  been  present  for  some  time  and  she  was  weak 
and  anemic.  The  chief  symptom  referable  to  the  genital  tract  was  leukor- 
rhea, which  was  moderately  profuse,  offensive,  and  occasionally  blood 
tinged.  A  pelvic  examination  showed  the  hymen  unruptured  and  the 
portio  vaginalis  the  seat  of  a  papillary,  fungus-like  outgrowth,  which 
was  covered  with  discharge  and  which,  on  touch,  was  soft,  friable,  and 
bled  easily.  Hysterectomy  was  performed  and  the  diagnosis  verified  by 
histologic  examination. 

Tate.111  Aged  36  years.  Nullipara,  married.  Had  an  operation  for 
the  removal  of  tuberculous  glands  of  the  neck  6  years  ago.  Had  an 
attack  of  pelvic  peritonitis  three  years  ago.  Dysmenorrhea  for  one  year. 
Examination  showed  cervix  enlarged  and  the  cervical  canal  extended  into 
a  large  cavity  filled  with  a  soft,  friable  growth.  A  portion  of  this  was 
removed  digitally,  and  histologic  examination  showed  tuberculosis.  The 
uterus  was  enlarged  and  the  appendages  involved.  Vagino-abdominal 
hysterectomy  and  bilateral  salpingo-oophorectomy.  The  ulcer  did  not 
extend  above  the  internal  os,  and  the  portio  vaginalis  was  fairly  normal. 
Recovery. 

Tedenat.112     The  patient  was  a  woman,  26  years  of  age,  who  had 


180   GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

been  married  three  years,  and  had  never  been  pregnant.  Amenorrhea. 
The  chief  local  symptom  was  discharge.  The  cervix  was  the  seat  of  a 
polypoid  vegetative  outgrowth,  which  was  moderately  soft  to  the  touch. 
The  diagnosis  of  cancer  Mas  made  clinically,  and  the  correct  etiology  of 
the  lesion  was  only  determined  by  histologic  examination.  The 
lesions  were  cauterized  and  treated  with  formalin,  with  some  im- 
provement. 

Addisell.113  The  author  exhibited  a  specimen  of  a  uterus  from  a 
tuberculous  woman,  in  which  tuberculosis  was  present  and  was  his- 
tologically demonstrated  as  extending  from  the  cervix  to  the  fundus. 

Bender.63  The  patient,  aged  34  years,  entered  the  clinic  September 
25,  191 1.  The  family  history  was  negative  for  tuberculosis.  There  was 
a  previous  history  of  measles,  scarlet  fever,  and  articular  rheumatism, 
and  an  acute  pneumonia  fourteen  years  ago.  She  was  a  tripara,  the  puer- 
perium  had  been  normal,  and  the  children  were  healthy.  The  chief  geni- 
tal symptom  was  a  profuse,  purulent  malodorous  discharge.  This  had  been 
present  for  four  years,  but  of  late  had  been  increasing  in  amount.  There 
was  pain  in  the  lumbar  region.  The  kidneys  were  normal,  as  were  the 
lungs.  Examination  revealed  some  tenderness  over  the  lower  abdomen. 
Pelvic  examination  showed  the  cervix  enlarged  and  engorged  with  blood, 
reddish  in  color,  and  on  the  posterior  lip  was  an  irregular,  granular,  pink- 
ish ulcer  partially  covered  with  exudate.  The  ulcer  was  moderately  soft 
and  friable.  On  account  of  the  possibility  of  cancer,  biopsy  was  per- 
formed, and  when  the  character  of  the  lesion  was  determined,  a  trache- 
lectomy  and  dilatation  and  curettage  was  performed.  Recovery  was  un- 
eventful, and  the  patient  was  well  2  years  later.  The  diagnosis  was 
finally  verified  by  histologic  examination  and  animal  inoculation. 

Popow.114  The  patient  was  a  multipara,  39  years  of  age,  who  pre- 
sented herself,  suffering  from  a  necrotic  ulcer  of  the  cervix.  Macro- 
scopically  the  lesion  was  suggestive  of  cancer,  and  biopsy  was  performed. 
On  account  of  the  advanced  character  of  the  lesion  and  involvement  of 
the  corporeal  portion  of  the  uterus  and  also  of  the  adnexa,  a  vaginal 
hysterectomy  was  performed.  In  addition  to  the  cervical  lesion,  there 
was  a  tuberculous  focus  in  the  anterior  uterine  wall  near  the  left  cornu. 
Tuberculous  salpingitis  and  endometritis  was  also  present.  Histologic 
verification. 

Stone  115  merely  mentions  a  case  operated  upon  by  Dr.  Cole.  Stone 
states  that  he  examined  the  specimen  and  that  there  was  no  tuberculosis 
found  in  any  other  portion  of  the  genital  tract  or  any  history  or  physical 
signs  of  tuberculosis  in  any  other  portion  of  the  body.  The  patient's 
husband  was  a  strong  healthy  man,  and  there  was  no  tuberculous  family 


TUBERCULOSIS  OF  THE  CERVIX  181 

history.  The  source  of  the  infection  could  not  be  determined,  but 
Stone  states  that  it  was  without  doubt  a  primary  tuberculosis  of 
the  cervix. 

Nicolo.116  Case  I.  The  patient  was  24  years  of  age.  Menstruated 
first  at  14  years.  Was  always  regular,  but  scant.  She  was  married  at 
18  years.  Had  suffered  from  cough  and  other  symptoms  of  pulmonary 
tuberculosis  for  some  time.  The  chief  symptoms  referable  to  the  genitalia 
were  discharge  and  bleeding.  The  bleeding  was  of  the  metrorrhagic  type 
and  often  followed  slight  trauma,  such  as  coitus,  etc.  The  discharge  was 
purulent  and  frequently  blood  stained.  Examination  showed  a  fungoid, 
ulcerating  mass,  occupying  the  position  of  the  cervix.  The  uterus  was 
antiflexed  and  movable.  Operation — Recovery.  Histologic  verification 
of  diagnosis. 

Case  2.  The  patient  was  a  married  woman,  40  years  of  age,  who 
had  had  a  number  of  children.  She  had  pulmonary  and  laryngeal  tuber- 
culosis, and  gave  a  history  of  lupus.  The  genital  symptoms  were  sug- 
gestive of  carcinoma — purulent,  frequently  blood  streaked  discharge,  and 
irregular  bleeding,  especially  following  trauma.  Examination  showed  a 
fungoid,  ulcerating,  friable  mass  originating  from  the  cervix.  His- 
tologic verification  of  the  diagnosis. 

Kynoch.117  The  patient  was  a  married  woman  of  45  years  of  age, 
who  had  a  family  history  of  tuberculosis.  For  3  months  there  had  been 
irregular  hemorrhages  per  vagina.  Pelvic  examination  showed  the 
external  genitalia  and  vagina  normal.  The  portio  vaginalis  was  nor- 
mal in  appearance  and  the  os  patulous.  The  cervical  canal,  especially 
the  anterior  surface,  was  the  seat  of  an  eroded  lesion.  Many  papillary 
outgrowths  were  present.  These  were  stated  not  to  have  been  friable, 
but  bleeding  followed  manipulation.  Biopsy  was  performed,  followed 
by  a  vaginal  hysterectomy.  The  diagnosis  rests  upon  histologic  veri- 
fication.    A  tuberculous  endometrium  was  also  present. 

Rossle.118  Autopsy  case.  Eighty-seven  years,  tuberculosis  of  the 
lungs,  fundus  of  the  uterus,  and  anterior  commissure.  An  ulcerative 
tuberculous  lesion  was  present  in  the  cervix. 

Moore.119  Age  27;  married;  negative  family  history;  husband 
sound ;  nullipara ;  normal  menstruation.  For  four  weeks  observed  spot- 
ting after  trauma.  Diagnosis,  cancer.  Correct  diagnosis  made  by  biopsy. 
Vaginal  hysterectomy.  Recovery,  but  considerable  foul  leukorrhea  and 
induration  of  vault  of  vagina  fifteen  months  later.  Histologic  examina- 
tion showed  tuberculosis  of  tubes,  fundus  of  uterus,  and  cervix,  the  oldest 
lesion  being  in  the  tubes.  In  the  uterus  and  cervix  the  tuberculosis  is 
limited  to  the  mucosa.     This  case  was  of  the  miliary  type. 


182        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

For  additional  cases  of  tuberculosis  of  the  cervix  the  reader  is  re- 
ferred to  the  chapter  dealing  with  lesions  of  the  vagina. 


TUBERCULOSIS  OF  THE  BODY  OF  THE  UTERUS 

Tuberculosis  of  the  uterus  may  occur  as  an  endometritis,  a  myome- 
tritis, or  a  perimetritis,  or  combinations  of  these  lesions  may  be  pres- 
ent. By  far  the  most  frequent  structure  of  the  uterus  to  be  attacked 
by  this  infection  is  the  corporeal  endometrium.  Infection  of  the  endo- 
metrium is  the  second  most  frequent  site  for  genital  tuberculosis. 

Endometritis. — Like  other  forms  of  genital  tuberculosis,  endo- 
metritis is  almost  always  secondary  to  tuberculosis  elsewhere  in  the 
body.  Gordeler,120  in  a  series  of  4,620  postmortems,  observed  one  case 
of  apparently  primary  tuberculous  endometritis,  that  occurred  in  a 
woman  68  years  of  age.  Our  experience  points  to  the  fallopian  tubes 
as  the  source  of  infection  in  the  large  majority  of  lesions  of  this  local- 
ity. A  study  of  our  cases  has  shown  that  in  not  a  single  instance  in 
our  series  has  the  endometrium  been  involved  without  a  concomitant  in- 
fection of  the  tubes.  Furthermore,  our  cases  seem  to  show  that  the 
tubes  harbor  the  primary  genital  lesion,  and  that  from  them  the  dis- 
ease spreads  as  a  descending  infection,  generally  by  continuity,  to  the 
endometrium  of  the  body  of  the  uterus.  Contamination  of  the  endo- 
metrium by  leakage  of  the  infected  tubal  contents  through  the  intra- 
mural portion  of  the  fallopian  tube  doubtless  also  accounts  for  a  cer- 
tain percentage  of  cases  of  tuberculous  endometritis.  The  fact  that,  in 
a  definite  proportion  of  specimens,  only  the  endometrium  in  the  im- 
mediate neighborhood  of  the  uterine  end  of  the  tube  has  been  involved, 
the  lower  portion  of  mucosa  of  the  body  of  the  uterus  being  normal, 
is  significant.  This  is  especially  likely  to  be  the  case  in  early  cases,  for, 
as  the  disease  advances,  the  entire  mucosa  often  becomes  invaded.  As 
in  endometritis,  the  result  of  organisms  other  than  tubercle  bacilli,  how- 
ever, the  entire  mucosa  is  not  as  a  rule  uniformly  attacked,  irregular 
areas  of  well  defined  inflammation  being  scattered  with  other  areas  either 
less  inflamed,  or  even  normal  endometrium.  When,  however,  an  endo- 
metritis is  present,  the  mucosa  in  the  cornua  of  the  uterus  is  nearly  al- 
ways invaded,  and  usually  the  seat  of  the  more  advanced  inflammation. 

Numerous  authorities  have  observed  tuberculous  endometritis  with- 
out tubal  involvement.  As  has  been  stated,  this  has  not  occurred  in 
any  of  the  cases  comprising  our  series,  and  it  is  a  generally  accepted 
fact  that,  if  the  endometrium  is  the  seat  of  a  tuberculosis,  the  tubes  are 


TUBERCULOSIS  OF  THE  CERVIX  183 

involved  in  the  great  majority  of  cases.  This  is  an  important  point  to 
be  considered  in  the  treatment  of  genital  tuberculosis.  In  other  words, 
where  a  tuberculous  endometritis  is  present,  the  tubes  are  also  involved 
in  the  large  proportion  of  cases,  and  this  fact  should  be  taken  into  con- 
sideration in  the  treatment  of  the  disease,  as  the  endometritis  cannot  be 
cured  if  constant  reinfection  is  occurring  from  above.  In  at  least  two 
cases  of  our  series  the  chief  symptom  was  leukorrhea,  the  symptoms 
resulting  from  the  tubal  lesion  being  of  minor  subjective  importance 
as  compared  with  those  arising  from  the  uterus. 

Tuberculous  endometritis  may  be  of  either  the  (1)  miliary,  or  (2) 
caseous  or  ulcerative  variety,  the  former  being  by  far  the  most  frequent, 
in  the  proportion  of  4  to  1  in  our  series.  In  this  variety  macroscopic 
lesions  are  not  always  present,  although  thickening  and  reddening  of 
the  endometrium  are  often  observed.  Tubercles  can  be  seen  in  some 
specimens  with  the  naked  eye,  but  in  many  they  are  inconspicuous  or 
even  undiscernible  except  with  the  microscope.  Characteristic  lesions, 
although  not  by  any  means  always  present  in  the  tubes,  are,  however, 
much  more  frequent  than  in  the  interior  of  the  uterus.  In  the  caseous 
variety  the  etiology  of  the  lesion  can  generally  be  determined  by  the 
macroscopic  appearance  of  the  specimen.  The  thickening  and  redden- 
ing of  the  mucosa,  with  perhaps  here  and  there  actual  ulcer  formation, 
and  the  characteristic  cheesy  particles  adherent  to  the  endometrium 
should  always  at  least  suggest  this  form  of  infection. 

As  in  other  forms  of  endometritis,  more  or  less  involvement  of 
the  underlying  myometrium  usually  occurs,  and  in  the  advanced  cases, 
especially  of  the  caseous  variety,  the  uterus  is  often  enlarged,  a  well 
marked  myometritis  being  present.  On  the  other  hand,  in  early  cases, 
especially  of  the  mild  type,  the  uterus  is  often  normal  in  appearance, 
and  only  upon  close  histologic  examination  will  any  involvement  of  the 
myometrium  be  found,  and  only  then  in  the  muscle  fibers  immediately 
underlying  the  infected  endometrium.  Tubercles  may,  of  course,  be 
present  upon  the  peritoneal  surface  in  any  of  the  varieties  of  uterine 
tuberculosis.  One  or  two  cases  have  been  observed  in  which  the  myo- 
metrium was  the  only  portion  of  the  uterus  involved.  Such  instances 
are,  however,  of  extreme  rarity  and  may  be  regarded  as  pathologic 
entities.  As  has  been  stated,  a  well  defined  perimetritis  is  a  frequent 
lesion  and  a  common  accompaniment  of  tuberculous  salpingitis. 
Kromer  20  has  recorded  an  unusual  case,  in  which  a  tuberculous  process 
had  perforated  the  posterior  uterine  wall,  forming  a  communication  be- 
tween it  and  Douglas'  cul  de  sac. 

As  in  tuberculosis  of  the  tubes,  no  age  is  immune.    The  disease,  how- 


184        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

ever,  most  frequently  occurs  during  the  active  sexual  life  of  the  indi- 
vidual. 

Symptoms. — The  symptoms  resulting  from  a  tuberculous  endo- 
metritis are  generally  more  or  less  masked  by  those  produced  by  the 
accompanying  salpingitis.  Less  frequently  the  converse  is  true.  As  in- 
fection of  the  endometrium  is  usually  antedated  by  a  similar  infection 
of  the  tubes,  a  close  analysis  of  the  history  of  the  case  will  usually 
show  that  symptoms  resulting  from  disease  of  the  latter  structures  have 
occurred  before  those  directly  attributed  to  the  uterus.  The  symptoms 
resulting  from  the  endometritis  alone  are  in  no  way  pathognomonic  of 
tuberculosis,  but  are  common  to  all  forms  of  chronic  endometrial  infec- 
tions of  the  uterine  mucosa.  Leukorrhea,  pain  or  tenderness  in  the 
lower  abdomen  are  perhaps  the  most  frequent.  The  leukorrhea  is  not 
usually  characteristic;  in  advanced  cases  of  the  caseous  variety  cheesy 
particles  may  be  present  in  the  discharge  and,  where  observed,  are  al- 
ways suggestive  of  this  form  of  infection.  The  leukorrhea  naturally 
varies  markedly  in  different  cases,  but  is  usually  moderately  profuse, 
at  first  thin,  in  the  latter  stages  becoming  purulent,  and  in  some  in- 
stances, especially  when  ulcers  are  present  in  the  uterine  mucosa,  blood 
stained.  The  presence  of  leukorrhea  without  evidence  of  infection  of 
the  lower  genital  tract,  especially  in  the  young  and  virginal,  should 
suggest  the  likelihood  of  tuberculosis  as  an  etiologic  factor.  In  gonor- 
rhea the  discharge  is  chiefly  cervical  in  origin.  Tuberculosis  exhibits 
a  strong  tendency  to  limit  its  downward  spread  to  the  internal  os,  so 
that  the  discharge  in  these  cases  is  corporeal  in  origin,  although  naturally 
more  or  less  mixed  with  the  normal  cervical  mucus.  The  leukorrhea 
consists  of  secretions  from  the  uterus  and  to  a  lesser  extent  from  the 
cervical  glands,  epithelium  debris,  and  leukocytes.  In  some  instances 
cheesy  particles  consisting  of  tuberculous  debris  may  be  present.  Tuber- 
cle bacilli  are  usually  present  in  the  discharge,  but  are  often  few  in 
numbers  and  difficult  to  demonstrate.  It  would  seem,  however,  that 
the  examination  of  the  discharge  for  tubercle  bacilli,  either  by  animal 
inoculation  or  by  smear  methods,  or  by  both,  in  suspicious  cases  is  a 
means  of  diagnosis  which  has  not  been  fully  taken  advantage  of  by 
many  observers. 

Pain  is  by  no  means  a  constant  or  reliable  symptom.  Pain  and  ten- 
derness in  the  region  of  the  uterus  are,  however,  suggestive  of  the  oc- 
currence of  an  endometritis.  How  much  of  the  dysmenorrhea  which 
these  patients  suffer  from  is  due  to  an  actual  uterine  involvement,  how 
much  to  the  usual  accompanying  adnexal  lesions,  is  difficult  to  determine. 
Pulmonary   tuberculosis   itself   often   produces   dysmenorrhea,    and   as 


TUBERCULOSIS  OF  THE  CERVIX  185 

many  of  these  patients  are  the  incumbents  of  pulmonary  lesions,  this 
may  account  for  some  of  the  cases  of  this  condition.  Certain  it  is 
that  cases  of  pelvic  peritonitis  of  tuberculous  origin  nearly  always  suffer 
from  dysmenorrhea,  usually  of  the  congestive  type,  the  pains  appearing 
some  hours  or  days  before  the  appearance  of  the  flow,  continuing  for 
the  first  few  days,  and  being  of  a  dull,  heavy  aching  character  in  the 
lower  abdomen  and  lower  lumbar  and  sacral  region.  Menstrual  irregu- 
larities, both  as  to  periodicity  and  amount  of  flow,  are  of  frequent  oc- 
currence, but  are  probably  more  the  result  of  the  primary  lesion  or 
of  the  ovarian  involvement  than  of  the  actual  endometritis. 

Diagnosis. — A  positive  diagnosis  is  practically  impossible,  unless 
tubercle  bacilli  can  be  demonstrated  in  the  discharge  or  the  tissue  is  ex- 
amined histologically.  The  absence  of  evidence  of  other  forms  of  in- 
fection, the  presence  of  a  tuberculosis  in  other  parts  of  the  body,  ex- 
treme youth  or  virginity,  are  all  suggestive  of  this  form  of  tuberculosis. 
As  has  been  stated,  uterine  involvement  is  usually  secondary  to  adnexal 
lesions,  so  that  much  of  what  will  be  said  regarding  the  latter  condition 
applies  to  tuberculous  endometritis. 

Treatment. — All  forms  of  local  application  are  valueless  in  this 
variety  of  infection.  Curettage,  followed  by  the  application  of  some 
bactericide,  such  as  the  tincture  of  iodin  or  formalin  solution,  or  in 
severe  cases,  hysterectomy,  are  the  two  forms  of  treatment  which  offer 
the  best  hope  of  cure.  Curettage  alone  is  not  indicated.  The  tubes 
are  nearly  always  involved,  and,  unless  an  operation  is  directed  towards 
them  at  the  same  sitting,  an  acute  exacerbation  of  the  salpingitis  is  likely 
to  occur.  For  this  reason  curettage  should  immediately  precede  all 
operations  for  tuberculous  salpingitis,  but  is  usually  contra-indicated 
under  other  circumstances.  Vaporization  has  been  employed  by  some 
operators.  The  introduction  of  live  steam  into  the  uterine  cavity  is  not 
without  danger.  The  author  believes  that  the  risks  attending  this  form 
of  treatment  are  greater  than  in  curettage  or  even  hysterectomy,  and 
that  the  results  are  not  so  satisfactory.  One  of  the  chief  disadvantages 
of  vaporizing  is  the  difficulty  of  actually  controlling  the  steam  and  as- 
certaining the  exact  depths  to  which  the  tissues  are  being  destroyed. 
The  endometrium  in  these  cases  varies  quite  widely  in  thickness  and 
what  would  be  sufficient  steam  to  boil  off  the  mucosa  in  one  case  might 
only  destroy  the  superficial  layer  in  another. 

Of  prime  importance  in  these  cases  is  the  treatment  of  the  adnexitis, 
and  the  question  of  whether  or  not  the  uterus  shall  be  removed  depends 
largely  upon  the  type  of  operation  practiced  upon  the  tubes  and  ovaries. 
When  it  is  necessary  to  remove  both  ovaries,  nothing  is  gained  by  the 


186   GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

conservation  of  the  uterus.  The  actual  condition  of  the  uterus,  whether 
enlarged,  etc.,  must  also  be  taken  into  consideration,  as  well  as  the  age 
of  the  patient,  the  condition  of  the  primary  lesion,  and  many  other  points 
which  will  be  considered  under  the  treatment  of  tuberculous  adnexitis. 
The  author  believes  that  in  all  cases,  regardless  of  symptoms,  a  curettage 
and  iodinization  of  the  uterus  should  precede  all  operations  upon  the 
adnexa  in  tuberculous  cases. 

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62.  Hamolle,  H.    Prog.  Med.  Obst.  in  Centrbl.  f.  Gyn.  1877.  No.  15. 

63.  Bender,  X.     Rev.  de  gyn.  et  de  chir.  abd.    191 1.    17:193.    1914. 

12  :29. 


188        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

64.  Peham,  J.    La  Gyn.   1908.   12:180. 

65.  Santi,  E.    La  gin.    1909.   6:257. 

66.  Deletrez.     Bui.   acad.   roy.   de  med.   de  Belg.     1907.    21  :6<48. 

Also,  Ann.  de  gyn.  et  d'obst.  1908.  5:26.  Also,  Rev.  mens. 
de  gyn.,  obst.,  ped.  1908.  p.  16.  Also,  Ann.  de  l'inst.  chir.  de 
Brux.    1908.    15:33.    Also,  La  gyn.    1908.    12:178. 

6y.  Everling,  K.    Berl.  Klin.  Woch.    1909.   46:1446. 

68.  Croft,  E.  O.    Jr.  Obst.  Gyn.  Brit.  Emp.    1902.    1  ^39. 

69.  Cullen,  T.  S.     Carcinoma  of  the  Uterus.    New  York,   1900. 

P-  193- 

70.  Driessen,  L.  E.    Ned.  tijdscr.  v.  verl.  en.  gyn.    1898.    9:66. 

71.  Baudet.    Toulouse  med.   1908.    10:193. 

y2.  Young,  E.  E.    Tr.  Obst.  Soc.  Lond.  1906.  48:286. 

73.  Nebesky.    Monschr.  f.  Gebh.  u.  Gyn.     1905.    22  :  No.  5. 

74.  Matthews,  F.  S.     N.  Y.  Med.  Rec.   1898.   p.  872. 

75.  Buscarlet.    Bui.  soc.  anat.  de  Paris.     1890. 

76.  Galabrin.    Tr.  Obst.  Soc.  Lond.   1906.  48:300. 
yy.  Reverdin.     Rev.  med.  de  la  Suisse  Rom.     1895. 

78.  Uhland.    Inaug.  Dis,  Tubingen,  1886. 

79.  Laboullene.     Elements  d'anatomie  pathologique.      1879.     Ab- 

stracted by  Chaton,  No.  4. 

80.  Parrot.    Quoted  by  Chaton,  No.  4. 

81.  Reclus.    These  de  Daurios.    1889. 

82.  Haby.    Monschr.  f.  Gebh.  u.  Gyn.    1907. 

83.  Godard.    Bui.  soc.  anat.  de  Paris.    1867. 

84.  Mayor.    Bui.  soc.  anat.  de  Paris.    1881.    Also,  Prog.  med.    1882. 

85.  Adenot.    Gaz.  hebd.  de  med.    1902. 

86.  Boldt,  H.  J.    Tr.  N.  Y.  acad.  med.     1902. 

87.  Cheron,  J.    Rev.  med-chir.  des  mal.  des  fern.    1886.   8:82. 

88.  Chiarabba.    Gior.  di  gin.  e  di  ped.    1904.   22:341. 

89.  Cornil,  V.    Bui.  soc.  med.  des  hop.   1879. 

90.  Fernel.    These  de  Paris.   1887. 

91.  Frerichs.    These  de  Nauard,  No.  43.    Quoted  by  Chaton,  No.  4. 

92.  Gummert.    Monschr.  f.  Gebh.  u.  Gyn.   1903. 

93.  Gottschalk,  S.    Arch.  f.  Gyn.    1903.   70:1. 

94.  Haidenthaler.      Wien.    Klin.    Woch.      1890.     3 1655.      Also, 

Centrbl.  f.  Gyn.   1891.   15:76. 

95.  Holmes,  C.    London  Med.  Gaz.   1830.    Quoted  by  Chaton,  No.  4. 

96.  Knauer,  K.  K.    Monschr.  f.  Gebh.  u.  Gyn.    17:554. 

97.  Lionville.    Bui.  soc.  anat.  de  Paris.     1873. 

98.  Rivilliod.    Bui.  soc.  anat.  de  Paris.    1884. 


TUBERCULOSIS  OF  THE  CERVIX  189 

99.  Richelot,  L.  G.     Chirurgie  de  l'uterus.     Also,  La  gyn.    1905. 
10:481.     Also,  Compt.  rend.  soc.  d'obst.,  gyn.,  paed. 

100.  von  Hauschka.    Wien.  Klin.  Woch.    1901. 

101.  Schultze.    Gyn.  Helv.    1905.   5:135. 

102.  Thompson.    Lancet.     1872. 

103.  Lisfranc,     Clin.  chir.  de  la  Pitie.     1842.    2:661. 

104.  Thiry.    Presse  med.  Beige.    1852.  4:1. 

105.  Walther.    Monschr.  f.  Gebh.  u.  Gyn.    1897. 

106.  Weigert.    Virch  Arch.     1876. 

107.  Winter.     Centrbl.  f.  Gyn.     1887. 

108.  Dunning,  J.,  et  Rigaud.     Provence  med.     191 1.     22:284. 

109.  Williams,  J.  D.    Brit.  Med.  Jr.    1895.    1 :968. 

no.  Maly,  G.  W.    Monschr.  f.  Gebh.  u.  Gyn.    1907.  26:219. 

in.  Tate.     Tr.  Obst.  Soc.  Lond.     1904.     46:138. 

112.  Tedenat.     Cong.  Franc,  de  chir.     1905. 

113.  Addisell.    Jr.  Obst.  Gyn.  Brit.  Emp.     1905.    8:348. 

114.  Popow.    Russky.  vratch.   1906.   No.  12,  13. 

115.  Stone.    Am.  Jr.  Obst.    1910.   61:98. 

116.  Nicolo,  R.  di.    Arch.  Ital.  di  gin.     1914.     17:61. 

117.  Kynoch,  J.  A.  C.    Brit.  Med.  Jr.    1903.   2:962. 

118.  Rossle.    Verhl.  d.  Deutsch.  Gesel.  f.  Gyn.    1911.   14:441. 

119.  Moore,  G.  A.    Surg.,  Gyn.,  Obst.    1919.   29:1. 

120.  Gordeler,  G.    Beitr.  z.  Klin.  d.  Tuberk.   1913.  28  :  No.  3. 

The  following  bibliography  should  be  consulted,  for  many  of  these 
papers  contain  reports  of  cases,  but  were  not  included  in  the  above  list, 
as  the  author  has  been  unable  to  obtain  references  to  some  of  the  original 
reports : 

Ajello,  A.    Rif.  med.      1900.    3:615  (primary  case). 

Amann,  J.    Monschr.  f.  Gebh.  u.  Gyn.     1902.     16:586-630. 

Archambault.    Gaz.  de  gyn.     1902. 

Attilio.    Med.  Blat.    1906. 

Basso.    Ann.  di  st.  e  gin.    1905. 

Baumgarten.    Berl.  Klin.  Woch.    1904. 

Beaulin.     Ann.  de  derm,  et  syph.     1903.  p.  54. 

Beyea,  H.  D.    Am.  Jr.  Med.  Sc.   1901.  v.  122  :  No.  6. 

Brouardel.    These  de  Paris.   1865. 

Cayla.  Contribution  a  l'etude  de  la  tuberculose  du  col  de  l'uterus 
Bordeaux,  191 2,  Gounouilhou. 

Chaton.    Bui.  Soc.  anat.  de  Paris.    1904. 

Cousyn.    Sem.  gyn.    1901. 


190        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Cruveilhier.    Quoted  by  Chaton,  No.  4. 

Daurios.    These  de  Paris.     1889. 

Delaunay  et  Darre.    Gaz.  des  Hop.    1905. 

Dervaux.    These  de  Lille.     1902. 

Deichmann,  W.  G.     Uber  einen  Fall  von  Primarer,  Papillarer 

Tuberkulose  an  der  Portio  Vaginalis  Uteri.     Leipzig.    1910. 

R.  Noske. 
Fintecus,  D.    Rev.  int.  de  la  tuberc.   1913.  23  :33c 
Gastany.    These  de  Montpellier.    1905. 
Giel.     Inaug.  Dis.  Erlangen.    1881. 
Gorowitz,  M.     La  tuberculose  genitale  chez  la  femme.     These 

de  Paris.    1900. 
Hartz.     Monschr.  f.  Gebh.  u.  Gyn.   1902.     v.   16. 
Heiberg.    Centrbl.  f.  Gyn.    1892. 
Jerie,  J.     Sborn.  lek.    1908.    9:1. 
Jerie,  J.    Rev.  de  med.  Tcheque.   1908.   1  :20. 
Kaposi.    Jr.  de  med.  de  Bordeaux.    1888. 
Kribich.    Soc.  Viennoise  de  derm.    May  8,  1901. 
Kuttner.    Beitr.  z.  Klin.  Chir.    1913.    13:583. 
Labadie-Lagarre  et  Leguen.     Traite  med-chir.  de  gyn.    1904. 
Lannes-Dehore,  L.     Contribution  a  l'etude  de  la  tuberculose  du 

col  de  l'uterus.     Lyon.    1905. 
Lassar.     Soc.  Viennoise  de  derm.    1891. 
Le  Denu.    Sem.  gyn.    1901. 
Leuret.    These  de  Paris.    1903. 
Limville.    Bui.  Soc.  Anat.  de  Paris.     1873. 
Martin.     Monschr.  f.  Gebh.  u.  Gyn.     1902.     v.  16. 
Muret.     Rev.  med.  de  la  Suisse  Rom.     Dec,  19 10.  p.  1050. 
Naudin,   L.      Contribution  a   l'etude   de   l'ulceration   du   col   de 

l'uterus.     Paris.     1885.     7:616-623.    Also,  1886,  8  :i34-i46. 
Popoff.     Inaug.  Dis.  St.  Petersburg.    1898. 
Pozzi.     Traite  de  Gynecologic     1907. 
Schenk.    Beitr.  z.  Klin.  Chir.    1896.    17:526. 
Schulze-Smiarkovska,   H.     Uber  einen  Fall  Tuberkuloser   Er- 

krankung   der   Portio  Vaginalis.      Zurich.     1904.     A.    Mark- 

walder. 
Sinety,  de.    Gaz.  med.  de  Paris.    1883.    5  :489. 
Taylor.     Lupus  of  the  Cervix  Uteri  and  Female  Genitalia,  New 

York.     1888.    J.  H.  Vail  &  Co. 
Thebierge.    Ann.  de  derm,  et  syph.    1896.   p.  1374. 
Vassmer.    Arch.  f.  Gyn.   v.  57. 


TUBERCULOSIS  OF  THE  CERVIX  191 

Voight.    Arch,  f .  Gyn.  69 :  No.  3. 

Weyl.    tiber  Localisierte  Tuberkulose  des  Collum  Uteri.   Giessen. 

1904.     R.  Lange. 
Williams,  J.  D.     Med.  Press  and  Circ.    1894.    58:228. 


CHAPTER  IX 

TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES 

Fallopian  tubes  and  ovaries  anatomically  and  symptomatically  considered  together — 
Predisposition — Routes  of  transmission — Histologic  examination — Factors — An- 
alysis of  cases — Study  of  acute  and  chronic  stages — Duration  of  acute  stage — 
Characteristics  of  chronic  stage — Other  forms  of  infection — Tuberculin  an  aid 
to  diagnosis — Differential  diagnosis  between  tuberculous,  gonococcal,  and  strepto- 
coccal pelvic  inflammatory  disease — Family  history — Prognosis — Cases — Methods 
of  treatment — Bibliography. 

General  Considerations. — Tuberculosis  of  the  fallopian  tubes  is 
a  comparatively  frequent  form  of  infection,  whereas  true  tuberculosis 
of  the  ovaries  is  relatively  infrequent.  However,  when  tuberculosis  of 
the  tubes  is  present,  a  peri-oophoritis  is  a  common  accompaniment.  For 
this  reason,  and  because  the  two  organs  are  so  closely  associated,  both 
anatomically  and  symptomatically,  tuberculosis  of  these  structures  will 
be  considered  together. 

Tuberculosis  of  the  tube,  like  tuberculosis  of  the  other  parts  of  the 
genital  tract,  is  usually  secondary  to  a  tuberculous  focus  elsewhere  in  the 
body,  pulmonary  tuberculosis  being  by  far  the  most  frequent  seat  of  the 
primary  disease.  Next  to  the  lungs,  the  peritoneum,  osseous  system, 
lymph  glands,  and  intestines  are  perhaps  the  most  frequent  sites  of  the 
primary  infection.  In  a  series  of  thirty  cases  from  the  gynecological  de- 
partment of  the  University  of  Pennsylvania  Hospital  which  have  been 
studied,  thirteen  showed  well  marked  pulmonary  lesions.  Of  the  thirteen, 
involvement  of  one  lung  was  present  in  nine,  and  in  the  remainder  both 
lungs  were  affected.  In  all  thejpulmonary  lesions  were  quiescent,  and  in 
none  was  the  disease  advanced.  The  material  from  which  these  statistics 
were  formulated  was  based  upon  operative  cases  only.  It  has  not  been  our 
custom  to  operate  upon  patients  in  whom  the  pulmonary  lesions  are  either 
acute  or  advanced,  and  for  this  reason  the  foregoing  statistics  are  some- 
what misleading. 

Albrecht  and  Schlimpert,1  in  a  series  of  autopsies  on  women,  found 
that  the  primary  source  of  the  genital  infection  was  as  follows :  lungs, 
73  per  cent;  intestines,  20  per  cent;  bones,  4  per  cent;  peritoneum,  2 
per  cent. 

192 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES      193 

The  frequency  with  which  the  tubes  are  affected  in  tuberculous  fe- 
males has  been  analyzed  in  previous  pages.  In  the  series  of  postmortem 
records  from  the  Henry  Phipps  Institute  studied  by  the  author  these 
organs  were  found  macroscopically  diseased  in  about  7  per  cent  of 
cases.  This  closely  corresponds  with  figures  given  by  other  observers. 
It  should,  however,  be  remembered  in  considering  postmortem  records 
that,  as  a  rule,  no  histologic  examination  was  made  of  the  fallopian 
tubes,  unless  these  structures  presented  macroscopic  lesions.  Williams  2 
has  very  properly  pointed  out  that  occasionally  histologic  examina- 
tions reveal  tuberculosis  in  macroscopically  normal  tubes,  and  this  fact 
should  be  taken  into  consideration  when  considering  the  above  figures. 
On  the  other  hand,  postmortem  records,  unless  confirmed  by  histologic 
examinations,  may  be  misleading,  in  that  gonococcus  or  other  pyogenic 
organism  may  produce  pathological  processes  in  the  fallopian  tubes  of 
tuberculous  women,  and,  unless  the  diagnosis  of  tuberculous  salpingitis 
is  confirmed  by  a  microscopic  examination,  may  cause  a  misconception 
regarding  the  type  of  the  infection  present. 

As  has  been  stated,  tuberculosis  of  the  tubes  is,  in  the  great  majority 
of  cases,  secondary  to  tuberculosis  in  some  other  parts  of  the  body.  A 
few  undoubted  primary  cases  of  tubal  tuberculosis,  however,  have  been 
recorded.  Thus,  Macnaughton-Jones  3  records  the  history  of  three  cases 
all  of  which  he  regards  as  primary  in  the  tubes;  two  of  these  cases  were 
unilateral,  and  in  one  both  tubes  were  involved.  Muller,4  Spanton,5  and 
Calzolari  6  have  also  recorded  the  histories  of  cases  of  primary  tubercu- 
losis of  the  fallopian  tubes.  In  Calzolari's  case  the  disease  was  appar- 
ently transmitted  by  coitus  from  an  infected  husband.  A  negative 
ophthalmo-reaction  was  present  subsequently  to  operation.  Murphy 7 
relates  a  similar  case.  Purefoy 8  states  that  18  per  cent  of  cases  are 
primary.  Our  own  studies  have  led  us  to  believe  that  primary  tubercu- 
losis of  the  tubes  is  a  rare  condition,  and  that  a  careful  study  of  the  case 
will  nearly  always  reveal  a  primary  lesion,  or  the  history  will  point  to 
a  previous  infection  by  the  tubercle  bacillus. 

In  our  series  there  were  two  cases  in  which  the  fallopian  tubes  were 
the  only  demonstrable  seat  of  tuberculosis  in  the  body ;  both  these  patients 
are  well  and  show  no  evidence  of  infection  since  operation,  which  in  one 
case  took  place  three,  and  in  the  other  five,  years  ago.  Great  care,  however, 
should  be  exercised  before  a  case  is  pronounced  as  primary,  for,  as  is 
well  known,  latent  foci  may  be  present  in  other  parts  of  the  body  which 
are  undemonstrable  by  any  known  means,  or  the  primary  lesion  may  even 
have  undergone  a  complete  resolution.  Not  a  few  gynecologists  and 
surgeons  even  deny  the  existence  of  primary  genital  tuberculosis.     A 


194        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

sufficient  number  of  cases  have,  however,  been  studied  at  autopsy,  and 
reported,  to  prove  the  existence  of  a  primary  infection,  although  it  is 
certainly  extremely  rare.  Furthermore,  the  existence  of  a  primary  in- 
fection of  the  genital  tract  has  been  demonstrated  by  animal  experi- 
mentation.    (See  Chapter  V.) 

The  tubes  are  the  portion  of  the  genital  tract  by  far  the  most  fre- 
quently attacked  by  tuberculosis.  It  is  generally  stated  that  the  tubes 
are  involved  in  90  per  cent  of  the  cases  of  genital  tuberculosis.  In  our 
laboratory,  where  all  operative  material  is  subjected  to  a  routine  his- 
tologic examination,  the  tubes  have  been  found  to  be  involved  in  all. 
It  would  seem,  therefore,  that  90  per  cent  is  an  under  rather  than  an 
over  estimate.  Tuberculosis  is  nearly  always  for  the  genital  tract  pri- 
mary in  the  tubes,  and  almost  invariably  secondary  to  tuberculosis  else- 
where in  the  body.  .  Mayer  9  states  that  of  40  cases  of  tuberculosis  in 
the  abdomen,  in  21  the  disease  was  situated  in  the  adnexa,  and  in  19 
was  definitely  peritoneal  in  origin. 

Tuberculous  salpingitis  constitutes  from  4  to  12  per  cent  of  all  tubal 
infections.     This  proportion  varies  somewhat  in  different  clinics. 

In  the  laboratory  of  gynecology  of  the  University  of  Pennsylvania 
this  form  of  infection  was  demonstrated  in  7.3  per  cent  of  all  pelvic 
infection.  Andrews  10  places  the  proportion  at  1  to  3  per  cent,  Menge  1X 
at  9  to  10  per  cent,  Kronig  12  at  7  to  8  per  cent,  Pankow  13  at  22  per 
cent,  Heynemann  14  at  11.7  per  cent.  Hurden  15  reports  that,  of  1,001 
cases  of  salpingitis  collected  from  the  Johns  Hopkins  Hospital  Reports, 
109  were  tuberculous.  Williams,2  from  the  obstetrical  department  of  the 
same  institute,  reports  4  per  cent  of  all  cases  of  salpingitis  due  to  the 
tubercle  bacillus. 

The  ovaries  are  comparatively  rarely  the  seat  of  a  true  tuberculous 
oophoritis,  although  peri-oophoritis  in  the  presence  of  tuberculous  sal- 
pingitis is  the  rule  rather  than  the  exception.  In  our  series  of  31  cases, 
true  oophoritis  was  present  in  4  cases,  peri-oophoritis  in  7,  while  of  the 
remaining  20,  5  showed  well  marked  retention  cysts.  It  is  difficult  to 
account  for  the  normal  structure  of  such  a  large  proportion  of  ovaries 
from  cases  of  tuberculous  salpingitis,  especially  when  it  is  considered 
that  the  mucosa  of  the  tube  is  practically  always  involved.  The  result 
is  the  formation  of  considerable  irritating  secretion,  which  is  poured  out 
in  the  peritoneal  cavity,  as  instanced  by  the  adhesions  found  about  these 
tubes.  Another  factor  which  would  seem  to  favor  the  infection  of  the 
ovaries  is  that  in  tuberculous  salpingitis,  the  abdominal  ostium  exhibits 
a  marked  tendency  to  remain  patulous,  thereby  offering  an  opening  for 
the  escape  of  the  tubal  contents,  which  drip  down  over  the  ovaries  inter- 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES      195 

mittently,  often  for  prolonged  periods.  Even  if  the  intact  surface  of 
the  ovary  were  able  to  withstand  the  infection  thus  brought  in  contact 
with  its  surface,  the  normal  rupturing  of  graafian  follicles  would,  it  might 
be  thought,  offer  an  avenue  for  infection.  Furthermore,  the  fact  that 
the  infecting  microorganisms  in  tuberculous  salpingitis  are  often  con- 
veyed to  the  tubes  by  the  blood  or  lymph  stream  and  the  close  anatomical 
relationship  of  the  blood  supply  to  the  tubes  and  the  ovaries  would  appear 
to  favor  infection  of  the  latter.  Practically,  however,  the  ovaries  are 
comparatively  rarely  infected,  much  less  frequently  than  in  pelvic  infec- 
tion from  the  gonococcus  or  other  pyogenic  organisms.  It  would  seem, 
therefore,  that  the  ovaries  must  possess  some  inherent  immunity  to  this 
form  of  infection.  The  fact  that  the  ovaries  are  involved  in  a  relatively 
small  proportion  of  cases  is  of  extreme  importance  when  considering  the 
surgical  treatment  of  tuberculous  pelvic  inflammatory  disease.  When 
actual  involvement  of  the  ovarian  stroma  occurs,  it  is  usually  the  result 
of  infection  gaining  access  to  the  ovaries  through  a  ruptured  follicle,  the 
lesion  often  being  an  abscess  of  a  corpus  luteum.  Horizontow  16  believes 
that  the  stroma  and  cortical  layer  of  the  ovary  are  most  frequently  at- 
tacked. Todorsky  17  has  especially  emphasized  the  gravity  of  ovarian 
complications,  and  believes  that  abscesses  and  even  fistulas  not  infre- 
quently follow. 

As  a  result  of  the  peri-oophoritis  which  is  so  frequently  present,  re- 
tention cysts  are  often  an  accompaniment,  and  malposition  of  the  ovaries 
due  to  adhesions  and  secondary  edema  is  not  uncommon.  Martin  has 
especially  called  attention  to  the  hypertrophy  of  the  ovaries  occurring 
in  these  cases.  Hypertrophy  has  not  been  frequent  in  our  series.  Pri- 
mary tuberculosis  of  the  ovaries  is  extremely  rare,  even  more  so  than  a 
similar  infection  of  the  tubes.  Senni  19  has,  however,  reported  the  history 
of  such  a  case. 

The  question  of  predisposition  towards  tuberculosis  of  the  genital 
tract  and  especially  of  the  fallopian  tubes  is  a  subject  which  has  promoted 
considerable  study  of  recent  years.  As  the  disease  is  secondary  in  the 
large  proportion  of  cases,  a  primary  focus  in  some  other  part  of  the  body 
is  perhaps  of  chief  importance.  Preexisting  inflammation  is  undoubtedly 
also  a  predisposing  factor.  In  tubal  infection  in  general  mixed  infections 
are  by  no  means  uncommon.  It  is  impossible  in  some  cases  to  determine 
whether  a  gonococcal  infection  is  superimposed  upon  a  tuberculosis,  or 
whether  the  reverse  is  the  case;  most  authorities  believe  that  the  latter 
is  the  more  frequent  condition,  and  that  once  the  tubal  mucosa  is  altered 
by  a  gonococcal  inflammation,  an  excellent  soil  for  the  development  of 


196        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

tuberculosis  is  prepared.  In  the  Pathological  Laboratory  of  Gynecology 
at  the  University  of  Pennsylvania  30  cases  of  tuberculosis  of  the  tubes 
have  been  examined  by  the  author.  In  20  of  these  the  history  or  his- 
tologic appearance  of  the  specimen  was  sufficiently  pronounced  to  cover 
this  point,  6  of  the  20  cases  had  apparently  been  preceded  by  a  Neisserian 
infection.  Owing  to  the  fact  that  the  bacteriologic  tests  have  not  been 
carried  out  in  a  routine  manner  in  many  of  these  cases,  it  is,  however,  im- 
possible to  definitely  determine  this  point.  Simmonds  20  was  one  of  the 
first  to  point  out  the  relationship  between  preexisting  inflammation  and 
tuberculosis  of  the  tubes.  Saulman  21  and  Schuchardt  22  have  also  empha- 
sized this  point. 

Bandelier  and  Roepke  23  state  that  marked  redundancy  and  folding 
of  the  plica  of  the  tubal  mucosa,  stagnation  of  the  tubal  secretion,  and 
poor  blood  supply  are  also  predisposing  factors.  These  latter  causes, 
however,  appear  to  the  author  to  be  somewhat  theoretic  and  unproven. 
Trauma  in  rare  instances  may  play  a  predisposing  part  in  tuberculous 
infection,  as  it  undoubtedly  does  in  other  parts  of  the  body.  The  nor- 
mal fallopian  tubes,  however,  owing  to  their  protected  position,  are  rarely 
the  subject  of  wounds  or  injuries  from  without.  Whether  or  not  heredity 
plays  a  predisposing  part  is  difficult  to  determine.  It  is,  however,  doubt- 
ful. Sellheim  24  and  Schiffmann  25  believe  that  hypoplasia  of  the  genital 
tract  favors  the  development  of  tuberculosis. 

The  age  of  the  patient  is  undoubtedly  an  important  factor,  patients 
of  certain  ages  apparently  exhibiting  a  greater  tendency  to  immunity  to 
this  type  of  infection  than  do  others.  Thus,  women  past  the  menopause 
are  comparatively  rarely  attacked  by  this  form  of  tuberculosis.  Chil- 
dren are  by  no  means  immune.  Bruning  26  has  collected  from  the  litera- 
ture 44  cases  of  genital  tuberculosis  occurring  in  the  young,  to  which  he 
adds  2  of  his  own.  In  the  majority  of  these  the  tubes  were  affected. 
Allaria  27  has  analyzed  19  cases,  all  of  which  are  reported  as  primary 
genital  infections.  Chaffey,28  Silcock,29  and  Collingworth  30  have  also 
recorded  cases  of  tuberculous  adnexitis  occurring  in  children. 

In  our  own  series  of  30  cases,  the  ages  varied  from  18  to  41,  2  being 
under  20  years,  1 5  between  20  and  30,  1 1  between  30  and  40,  and  2  be- 
tween 40  and  50.  In  Cummins'31  series  of  21  cases  the  ages  were  as 
follows:  1  case  between  10  and  15,  2  between  15  and  20,  7  between  20 
and  25,  3  between  25  and  30,  4  between  30  and  35,  2  between  35  and  40, 
1  between  40  and  45,  1  between  45  and  50.  No  age  is  immune.  This 
disease  is,  however,  most  frequent  during  the  active  sexual  life. 

Symptoms. — The  symptoms  produced  by  tuberculous  adnexitis  are 
by  no  means  characteristic,  and  differ  to  no  marked  degree  from  those 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES     197 

produced  by  other  microorganisms.  Pain,  tenderness,  sometimes  slight 
enlargement  of  the  lower  abdomen,  dysmenorrhea  or  other  menstrual 
disturbances,  sterility,  dyspareunia,  leukorrhea,  constipation,  nausea, 
vomiting,  and  evidences  of  a  local  peritonitis  with  fever,  leukocytosis 
are  among  the  most  important.  Hegar  32  has  divided  the  disease  into 
two  stages,  one  in  which  the  pelvic  organs  can  be  identified  by  palpa- 
tion, and  one  when  they  are  matted  together,  forming  an  indistinguish- 
able mass.  For  the  purpose  of  study,  however,  the  division  into  the 
acute  and  chronic  stages  seems  more  satisfactory.  Patel  33  divides  tubal 
lesions  into  four  classes:  where  tubal  lesions  are  the  most  prominent; 
where  general  peritonitis  is  the  most  prominent ;  where  the  ovarian  lesion 
is  the  most  prominent ;  where  local  complications  are  the  most  prominent. 
Under  the  last  heading,  Patel  mentions  peritonitis  causing  intestinal  ob- 
struction, spontaneous  evacuation  of  an  abscess  into  the  intestine,  ureter, 
bladder,  vagina,  uterus,  or  through  the  skin.  Murphy 34  states  that, 
unless  there-  is  a  mixed  infection,  there  is  a  strong  tendency  for  the  tube 
to  stay  open  and  that,  while  this  condition  exists,  the  course  of  the  dis- 
ease is  similar  to  that  of  recurrent  appendicitis — a  period  of  relief  or 
even  good  health  followed  by  a  sudden  attack  of  pain,  nausea,  vomiting, 
local  tenderness,  fever  and  often  a  discernible  effusion  in  the  peritoneal 
cavity — but  that,  when  the  tube  is  closed,  the  recurrent  type  of  symptoms 
is  not  present. 

This  is  undoubtedly  correct  in  theory.  Practically,  however,  it  seems 
probable  that  the  closure  of  the  distal  end  of  the  tube  is  often  temporary 
and  that,  as  a  result  of  a  lighting  up  of  the  infection,  which  produces 
an  increase  in  the  intratubal  pressure,  or  of  trauma,  etc.,  formerly  en- 
capsulated pus  or  other  secretion  within  the  tube  oozes  out  through  the 
external  abdominal  ostium  and  sets  up  a  fresh  attack  of  pelvic  peritonitis. 
The  tube  may  subsequently  become  walled  off  or  the  abdominal  ostium 
again  close  and  result  in  an  amelioration  of  the  subjective  symptoms. 
In  other  cases  the  tubal  opening  may  become  permanently  closed  and  this, 
as  Murphy  states,  results  in  more  or  less  permanent  lessening  of  the 
symptoms. 

Evens  35  states  that  in  a  definite  proportion  of  cases  the  previous 
history  shows  that  there  have  been  obscure  attacks  of  peritonitis  during 
girlhood,  and  that  these  are  not  infrequently  followed  by  amenorrhea. 
In  some  cases  the  pelvic  symptoms  are  preceded  by  those  of  a  general 
peritonitis,  often  of  the  ascitic  variety,  which  clears  up  and  leaves  behind 
a  more  or  less  well  marked  pelvic  inflammatory  disease ;  or  the  reverse 
may  be  the  case.     See  chapter  on  General  Tuberculous  Peritonitis. 

Acute  Stage. — During  this  stage,   the  patient  exhibits  the  usual 


198        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

symptoms  of  an  acute  pelvic  peritonitis,  the  severity  of  the  attacks  vary- 
ing with  the  individual  cases  and  with  the  extent  of  the  lesion  and  the 
previous  duration  of  the  disease.  Thus,  if  the  inflammatory  processes 
are  entirely  walled  off  from  the  general  peritoneal  cavity,  the  symptoms 
are  less  marked  than  where  an  inflammatory  tube  is  pouring  forth  an 
irritating  secretion  into  the  general  peritoneal  cavity.  The  subjective 
symptoms  are  similar  to  those  of  metritis,  except  that,  where  the  tubes 
are  involved,  the  pain  and  tenderness  are  more  marked  and  are  chiefly 
observed  in  the  ovarian  region.  As  tuberculous  salpingitis  is  usually 
bilateral,  pain  is  generally  complained  of  on  both  sides  of  the  uterus,  the 
entire  lower  abdomen  being  tender.  Bumm  36  and  Menge  37  have  very 
properly  pointed  out  that  tubal  infections  in  general  are  more  painful 
than  are  similar  infections  of  the  uterus.  In  the  latter  case  the  pain  is 
often  a  marked  symptom  only  at  the  menstrual  periods.  As  a  general 
rule,  the  onset  of  the  symptoms,  resulting  from  tuberculous  adnexitis, 
is  less  marked  and  more  insidious  than  in  the  ordinary  forms  of  pelvic 
inflammatory  disease. 

The  symptomatology  of  tuberculous  adnexitis  is  difficult  to  define, 
because  of  the  numerous  structures  which  may  be  involved  and  which 
may  in  themselves  produce  special  symptoms.  Thus,  if  a  tuberculous 
tube  becomes  adherent  to  the  bladder,  vesical  irritability  and  other  symp- 
toms suggestive  of  a  cystitis  are  likely  to  occur,  whereas,  if  the  tube  be 
plastered  against  the  rectum,  painful  defecation  occurs  and  as  a  result 
constipation  frequently  follows.  Cuturi,38  as  a  result  of  experiments, 
states  that  when  the  bladder  is  in  contact  with  a  diseased  tube,  the  former 
not  infrequently  shows  a  tuberculous  cystitis  at  the  point  of  contact. 
This  may  be  a  localized  or  a  general  cystitis.  The  author  has  observed 
two  such  cases.  Unless  this  complication  is  borne  in  mind,  the  danger 
of  a  mistaken  diagnosis,  and  considering  the  case  one  of  renal  tuberculo- 
sis, is  not  unlikely. 

The  onset  of  the  disease  is  frequently  marked  by  a  chill,  followed  by 
nausea,  vomiting,  malaise,  headache,  elevation  of  temperature,  and  in- 
creased pulse  rate.  The  temperature  varies  during  the  height  of  the  dis- 
ease from  ioo°  to  1050  F.,  1010  or  102. 50  F.  being  perhaps  the  average 
evening  rise.  A  blood  count  may  show  a  moderate  leukocytosis,  which, 
however,  is  usually  lower  than  in  other  forms  of  pelvic  inflammatory 
disease  or  the  white  count  may  be  normal.  The  appetite  is  lost  and  the 
usual  symptoms  of  fever  are  present.  The  severity  and  duration  of  the 
attack  vary  markedly  in  different  cases,  and,  as  in  gonococcal  infections, 
the  local  symptoms  are  only  a  moderately  reliable  indicator  of  the  extent 
of  the  disease.     When  pulmonary  tuberculosis  is  present,  the  coughing 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES       199 

often  markedly  increases  the  pelvic  pain.     In  some  cases  observed  by 
the  author  this  has  been  a  distressing  feature  of  the  case. 

An  attempt  has  been  made  in  the  study  of  our  cases  to  determine  if, 
in  tuberculous  cases,  the  tubes  were  especially  prone  to  be  attacked  at  any 
particular  stage  of  the  menstrual  cycle.  The  data  which  were  obtained 
showed  that  cases  might  be  attacked  at  any  time,  but  that  invasion  of 
the  tube  appeared  to  be  most  frequent  during  the  end  of  the  second  and 
the  beginning  of  the  third  week  following  the  beginning  of  the  menstrual 
period,  in  this  way  differing  from  the  gonococcal  cases,  in  which  exten- 
sion to  the  tubes  is  prone  to  occur  at  or  immediately  following  menstrua- 
tion. One  striking  point  brought  out  by  our  study  was  that,  in  the  large 
proportion  of  our  cases,  55  per  cent  plus,  there  was,  or  had  shortly  before 
been,  an  accentuation  of  the  primary  lesion  in  the  lungs  or  elsewhere, 
just  prior  to'  the  onset  of  the  pelvic  symptoms.  In  many  cases  the  ex- 
acerbation of  the  primary  lesion  was  slight,  but  careful  questioning  and 
examination  showed  that  it  had  been  present  frequently. 

The  duration  of  the  acute  stage  is  uncertain,  but  as  a  rule  this  period 
lasts  longer  and  is  more  resistant  to  palliative  treatment  than  are  the  in- 
fections produced  by  the  ordinary  pyogenic  organisms. 

A  general  peritonitis  may  either  precede  or  follow  the  tubal  infec- 
tion. The  former  class  of  cases  will  be  considered  in  a  subsequent  chap- 
ter. The  possibility  of  a  general  involvement  of  the  peritoneal  cavity 
following  the  tubal  infection  is  a  very  real  one.  When  the  susceptibility 
of  the  peritoneum  to  the  action  of  the  tubercle  bacillus  is  taken  into  con- 
sideration, and  the  vast  number  of  tubercle  bacilli  which  are  present  in 
the  tubal  secretion,  much  of  which  is  being  passed  out  into  the  peritoneal 
cavity,  it  is  only  remarkable  that  more  cases  of  general  tuberculous  peri- 
tonitis do  not  result.  Some  cases  run  an  acute  or  subacute  course  from 
the  onset,  rapidly  developing  a  general  peritonitis,  and  terminate  fatally. 
No  hard  and  fast  rule  can  be  laid  down  in  this  respect.  As  a  general  rule, 
however,  it  would  seem  that  those  cases  which  are  depleted  as  a  result  of 
a  primary  focus  of  the  disease  at  the  time  of  onset  of  the  pelvic  symptoms 
offer  less  resistance  and  are  more  subject  to  a  general  peritonitis  or  a 
fatal  termination  than  are  those  patients  in  whom  the  tubal  involvement 
occurs  early  and  who  are  in  good  general  condition  at  the  time  of  the 
beginning  of  the  pelvic  infection. 

Examinations  during  the  acute  stage  will  show  more  or  less  disten- 
tion of  the  abdomen,  but,  unless  there  is  a  general  peritonitis,  the  enlarge- 
ment tends  to  be  limited  to  the  lower  portion.  Tenderness  and  rigidity 
are  especially  marked  over  the  affected  areas.  Smith  30  has  called  atten- 
tion to  the  behavior  of  the  abdominal  cutaneous  reflexes  in  acute  condi- 


200        GYNECOLOGICAL  AXD  OBSTETRICAL  TUBERCULOSIS 

tions  within  the  abdomen  and  pelvis.  The  reflex  is  tested  by  striking  the 
skin  over  the  suspected  area  with  some  blunt  instrument,  often  the  blunt 
end  of  a  pencil.  Further  reference  to  the  subject  of  abdominal  cutaneous 
reflexes  may  be  found  in  the  works  of  Pflasterer,49  Miiller  and  Seidel- 
mann,41  Rosenbach,42  Van  Gehuchten,43  Striimpell,44  Bodon,45  Jamin,46 
Sicard,47  and  Rolleston.4S 

A  pelvic  examination  will  reveal  the  uterus  either  normal  in  size  or 
slightly  enlarged,  and  induration  can  be  felt  in  one  or  usually  both  va- 
ginal fornices.  The  cervix  is  more  or  less  fixed,  and  attempts  to  move  it 
cause  pain.  This  is  a  valuable  diagnostic  sign  of  all  varieties  of  pelvic 
inflammatory  disease.  An  inflammatory  mass,  varying  according  to  the 
extent  and  character  of  the  lesion,  from  slight  thickening,  induration  or 
indistinct  sense  of  resistance,  to  a  tumor  the  size  of  a  grape  fruit  or 
even  larger,  will  be  found  occupying  the  region  of  the  appendages.  As  a 
rule  the  lesions  are  not  especially  massive,  except  in  advanced  cases, 
when  enormous  masses  composed  of  the  inflammatory  adnexa,  omentum, 
intestines,  and  collections  of  serum  or  pus,  may  be  present. 

During  the  acute  stage,  owing  to  tenderness  and  tympanites,  it  is 
generally  impossible  accurately  to  outline  the  adnexal  lesions. 

Chronic  Stage. — The  chronic  stage  can  usually  be  traced  to  an  acute 
attack,  but  occasionally  the  disease  is  subacute  from  the  onset  and  fol- 
lows an  almost  chronic  course  from  the  beginning.  Indeed  an  insidious 
onset  is  more  frequent  in  this  than  in  any  other  variety  of  pelvic  inflam- 
matory disease.  As  in  the  acute  stage,  the  symptoms  vary  markedly  with 
the  individual  case.  As  a  rule,  to  which  many  exceptions  occur,  the  dis- 
ease tends  to  run  a  prolonged  chronic  course,  interspersed  with  acute  or 
subacute  attacks.  Marked  exacerbations  are  thought  by  some  observers 
to  occur  only  in  the  presence  of  mixed  infection.  The  general  health  is 
as  a  rule  poor,  usually  more  so,  perhaps,  as  a  result  of  the  primary  lesion 
than  actually  caused  by  the  pelvic  trouble,  although  there  is  no  certainty 
in  this  respect.  These  patients  therefore  are  apt  to  be  thin,  losing  weight, 
and  often  run  a  slight  evening  temperature,  especially  at  the  menstrual 
periods.  As  a  result  of  adhesions,  purulent  material  may  be  walled  off 
and  result  in  long  periods  of  latency. 

Secondary  anemia  of  varying  severity  occurs  in  over  80  per  cent  of 
cases.  As  has  been  stated,  the  symptoms  resulting  from  the  pelvic  lesions 
are  by  no  means  characteristic  of  tuberculosis,  but  are  more  or  less  com- 
mon to  pelvic  inflammatory  disease  in  general.  Menstrual  disturbances 
are  usually  present  and  may  be  either  due  to  an  accompanying  endometri- 
tis, or  metritis,  or  to  ovarian  involvement.  Pulmonary  tuberculosis  in 
itself,  without  pelvic  involvement,  is  prone  to  produce  menstrual  disturb- 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES      201 

ances,  a  subject  which  will  be  considered  in  detail  in  a  subsequent  chap- 
ter. An  analysis  of  our  30  cases  showed  that  all  suffered  more  or  less 
from  menstrual  disturbances;  in  1  case  amenorrhea  had  been  present  for 
three  months  and  menstruation  had  been  scanty  and  irregular  for  nine 
months;  15  showed  some  tendency  towards  irregularity  and  scantiness 
of  flow ;  in  14  the  flow  was  normal,  or  increased  in  amount ;  in  5  the 
periods  were  too  frequent;  in  27  more  or  less  dysmenorrhea  was  present, 
and  in  21  this  was  quite  a  marked  feature.  Although  the  character  of 
the  dysmenorrhea  may  vary,  it  is  usually  of  the  congestive  type.  It  gen- 
erally begins  12  to  48  hours  or  even  more  before  the  appearance  of  the 
menstrual  flow  and  becomes  less  severe  after  the  second  or  third  day. 
The  pain  is  of  a  dull,  heavy,  aching  character,  is  worse  over  the  lower 
abdomen,  and  is  generally  accompanied  by  backache  and  malaise.  During 
the  dysmenorrhea  the  general  tenderness  over  the  lower  abdomen  is  in- 
creased. Slight  tenderness  and  enlargement  of  the  inguinal  lymphatic 
glands  is  sometimes  present  at  this  time. 

The  dysmenorrhea  in  these  cases  may  result  from  the  primary  lesion, 
from  congestion  of  the  diseased  pelvic  organs,  especially  the  endome- 
trium, may  be  ovarian  in  origin,  or  from  a  combination  of  these  causes. 
Barbour  and  Watson  49  believe  the  dysmenorrhea  is  usually  ovarian  in 
origin,  and  is  caused  by  a  subalbugineal  castration.  It  is  noticeable  that 
in  all  our  cases  in  which  the  flow  was  increased  in  amount  there  was 
either  an  ovarian  involvement  or  a  well  defined  tuberculous  endometritis, 
or  both,  showing  that  salpingitis  alone  has  little  or  no  effect  upon  the 
regularity  or  amount  of  the  menstrual  flow.  This  is  in  accordance  with 
the  findings  of  Boldt,50  who  states  that  in  tubal  disease,  when  not  asso- 
ciated with  ovarian  lesions,  the  menstrual  flow  is  not  likely  to  be  changed. 
In  a  series  of  45  cases  of  tuberculous  salpingitis,  Baisch  51  observed  men- 
strual disturbances  in  50  per  cent.  It  is  probable  that  in  these  cases  there 
was  some  ovarian  involvement  in  the  majority  of  cases.  As  tuberculous 
salpingitis  is  usually  bilateral,  sterility  is  usually  the  result,  despite  the 
fact  that  in  more  than  half  the  cases  at  least  one  tube  is  patulous.  In 
this  connection,  however,  it  is  important  to  remember  that  the  tubercu- 
lous tube  exhibits  a  remarkable  tendency  to  remain  patent,  much  more 
so  than  do  tubes  affected  with  any  other  variety  of  infection. 

Pain  is  usually  a  more  or  less  pronounced  symptom,  although  Kelly  52 
remarks  upon  the  frequent  absence  of  this  symptom  in  children.  The 
pain  is  usually  general  over  the  lower  abdomen  and  is  usually  intensified 
at  the  menstrual  periods.  Defecation  is  often  painful,  especially  in  those 
cases  in  which  the  appendages  are  adherent  to  the  rectum.  As  a  result 
of  this  pain  a  constipated  habit  is  often  acquired.     The  accumulation  of 


202        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

hard  feces  within  the  pelvis  tends  in  time  to  augment  the  pelvic  inflam- 
mation, and  in  this  manner  a  vicious  circle  is  established.  In  some  pa- 
tients the  symptoms  resulting  from  the  sluggish  action  of  the  bowels  con- 
stitute in  themselves  a  marked  feature  in  the  case.  If  the  inflamed 
adnexa  lie  anterior  and  are  adherent  to  the  bladder,  vesical  symptoms, 
such  as  frequent  micturition  and  dysuria,  are  more  or  less  pronounced, 
and  unless  a  pelvic  examination  is  made,  the  condition  may  be  mistaken 
for  an  uncomplicated  case  of  cystitis.  Distention  of  the  bladder  and 
emptying  of  it  may  also  cause  pain.  Backache,  chiefly  in  the  lower  lum- 
bar and  sacral  regions,  is  not  infrequent,  and  frontal  or  occipital  head- 
aches may  occur.  During  the  chronic  stage  fever  as  a  result  of  the  pelvic 
lesions  is  often  absent,  although  an  evening  rise,  especially  in  cases  in 
which  there  is  pulmonary  involvement,  is  very  characteristic.  Not  infre- 
quently in  fairly  quiescent  cases  the  rise  will  be  but  slight,  often  not 
more  than  a  fraction  of  a  degree.  A  slight  evening  rise  is  an  extremely 
suggestive  symptom.  A  slight  rise  in  temperature  following  a  pelvic 
examination  is  common  to  all  types  of  pelvic  inflammatory  disease  and 
is  a  valuable  diagnostic  symptom  in  those  cases  in  which  the  pelvic  lesions 
are  small  or  palpation  difficult.  During  the  chronic  stage  there  is  usually 
no  leukocytosis  or  only  a  slight  increase  above  the  normal.  All  the  symp- 
toms are  likely  to  be  worse  in  the  afternoon  after  the  patient  has  been 
upon  her  feet,  and  are  ameliorated  by  rest  in  bed.  The  discomfort  is 
increased  by  exercise  and  pressure,  such  as  may  be  produced  by  tight 
clothing  about  the  waist  or  lower  abdomen. 

The  vermiform  appendix  is  secondarily  involved  in  a  definite  propor- 
tion of  cases,  and  as  a  result  tenderness  over  McBurney's  point  is  not 
infrequent,  but  is  perhaps  less  often  present  than  in  gonococcal  infections. 
In  our  30  cases  of  tuberculous  salpingitis  more  or  less  appendiceal  in- 
volvement was  present  in  10;  in  3  of  these  tuberculous  appendicitis  was 
present,  and  in  7  peri-appendicitis. 

As  has  been  mentioned,  the  severity  of  constitutional  symptoms 
varies  widely  in  different  cases.  They  are  more  frequent  and  pronounced 
in  these  than  in  the  gonococcal  variety  of  chronic  pelvic  inflammatory 
disease.  This  is  due  to  the  fact  that  in  a  large  majority  of  cases  the 
constitutional  symptoms  are  due  not  alone  to  the  pelvic  lesions,  but  are 
also  often  caused  by  the  primary  infection  in  the  lungs  or  elsewhere. 
The  patient  is  usually  more  or  less  incapacitated  and  tires  easily.  Usu- 
ally loss  of  weight  and  general  ill  health  are  present,  although  cases  vary 
markedly  in  this  respect.  Tenderness  over  the  lower  abdomen  is  often 
marked,  and  in  severe  cases  the  gait  may  be  almost  characteristic,  the 
patient  walking  slowly,  stooping  forward,  often  inclining  to  one  side  or 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES      203 

the  other,  a  hand  being  placed  over  the  site  of  the  pain.  These  patients 
may  be  observed  to  lower  themselves  carefully  into  a  chair,  and  are  apt 
to  sit  stooping  forward,  often  bending  towards  the  side  of  greatest  pain. 
The  same  cautious  action  is  observed  when  the  woman  arises  out  of  the 
chair  and  at  all  times  care  is  exercised  to  guard  the  abdomen  from  trauma 
or  jolts  of  any  kind,  such  as  getting  out  of  a  street  car,  or  going  down 
steps,  etc.  During  the  latter  maneuver  the  patient  is  likely  to  step  down 
somewhat  sideways,  one  step  at  a  time,  in  the  meantime  holding  on  to 
the  hand  rail,  somewhat  after  the  manner  sometimes  adopted  by  young 
children.  Dyspareunia  is  usually  present,  and  as  a  result  of  prolonged 
suffering  and  general  ill  health,  neurasthenia  not  infrequently  results. 

Abdominal  palpation  reveals  the  presence  of  resistance  and  tender- 
ness over  the  affected  areas,  and  in  thin  subjects  or  where  the  lesions 
are  massive  a  tumor  may  be  sometimes  felt  in  one  or  both  ovarian  regions. 

Vaginal  examinations  show  induration  and  tenderness  in  one  or  both 
vaginal  fornices.  The  cervix  is  more  or  less  fixed  and  attempts  to  move 
it  in  any  direction  cause  pain  in  the  ovarian  regions  and  along  the  broad 
ligaments.  The  uterus  is  often  in  retrodisplacement  and  adherent,  and 
in  those  cases  where  there  is  a  metritis  it  is  enlarged. 

The  tube  and  ovary  are  often  bound  together,  forming  an  indistin- 
guishable, adherent,  tender,  inflammatory  mass,  over  which,  in  cases  of 
large  accumulations  of  fluid,  fluctuation  may  be  elicited.  Fluctuation  is 
more  likely  to  be  noticeable  in  thin  patients,  and  in  those  cases  in  which 
massive  lesions  are  present.  More  often  fluctuation  is  absent  and  the 
tumor  has  a  hard  elastic  feel.  There  may  be  bulging  into  one  or  both 
vaginal  fornices.  In  some  cases  the  ovary  can  be  palpated  as  a  separate 
structure,  either  normal  or  increased  in  size.  In  many  cases,  however, 
it  cannot  be  differentiated  until  the  abdomen  is  opened.  As  a  rule  the 
condition  is  bilateral,  although  frequently  the  pathologic  process  is  more 
massive  on  one  than  on  the  other  side. 

In  our  series  28  cases  were  bilateral,  2  were  unilateral,  and  even  the 
latter,  owing  to  the  difficulty  in  macroscopic  diagnosis,  are  doubtful,  as 
in  these  2  cases  the  tubes  appeared  entirely  normal  and  were  not  re- 
moved, the  character  of  the  infection  being  unsuspected  by  the  surgeon 
at  the  time  of  operation.  The  longer  the  duration  of  the  case,  and  the 
more  acute  the  symptoms,  the  more  massive  are  the  lesions  likely  to  be. 
Occasionally  small  lesions  will  produce  marked  symptoms  and  the  con- 
verse may  also  occur,  especially  when  the  collections  are  serous  in  char- 
acter and  the  general  peritoneal  cavity  is  uninvolved.  Occasionally 
nodules  can  be  felt  in  the  Douglas  pouch,  and,  when  present,  are  very 
suggestive  of  this  type  of  infection.     The  differentiation  between  puru- 


204        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

lent,  serous,  and  hematogenous  collections  is  extremely  difficult  by  pal- 
pation alone.  In  purulent  cases  a  slight  rise  of  temperature  of  a  half  or 
one  degree,  following  examination,  is  significant.  On  palpation  a  pyosal- 
pinx  frequently  imparts  a  hard  resistant  sensation  to  the  examiner's 
finders,  whereas  serous  collections  are  more  elastic  and  often  less  ad- 
herent.  Hydrohematosalpinges  give  the  same  general  sensation  on  pal- 
pation as  do  simple  serous  accumulations.  The  typical  retort  shape, 
often  assumed  by  non-purulent  tubal  accumulations,  sometimes  acts  as 
a  guide  in  determining  the  variety  of  the  lesion  present.  This  shape  is 
relatively  frequent  in  cases  of  tubal  tuberculosis,  in  which  form  of  in- 
fection the  lesions  are  nearly  always  most  marked  in  the  ampulla  of  the 
tube,  and  not  infrequently  the  inner  two  thirds  of  the  organ,  being  com- 
paratively normal  or  somewhat  drawn  out,  forms  a  sort  of  pedicle.  Such 
tubes  may  undergo  torsion  and  upon  palpation  may  be  mistaken  for  cys- 
tic ovarian  neoplasms.  The  rare  cases  of  hematosalpingitis  not  due  to 
tubal  pregnancy  impart  a  soft  doughy  feel  to  the  examiner's  finger. 

Occasionally,  especially  in  the  early  stages,  the  tubes  are  small  and 
soft,  and  in  these  cases  the  demonstration  of  salpingitis  by  means  of  pal- 
pation is  extremely  difficult.  Even  after  the  administration  of  a  general 
anesthetic,  this  may  be  almost  impossible.  Tenderness  over  the  tube  and 
fixation  of  the  ovary  are  always  significant.  It  is  especially  in  these 
cases  that  an  accurate  history  is  of  great  importance  in  arriving  at  a 
correct  diagnosis. 

Diagnosis. — As  in  most  other  affections,  whether  of  the  genital 
tract  or  elsewhere,  the  correct  diagnosis  may  be  either  easy  or  extremely 
difficult  to  arrive  at.  The  fact  that  a  pelvic  peritonitis  is  present  is 
usually  easily  ascertained.  The  determination  of  the  variety  of  infec- 
tion is,  however,  in  many  cases  more  difficult.  Not  infrequently  the 
pelvic  symptoms  are  more  or  less  masked  by  those  produced  by  the  pri- 
mary lesion.  In  some  cases  an  absolute  diagnosis  is  impossible,  and  a 
tentative  diagnosis,  arrived  at  by  exclusion  of  the  ordinary  forms  of 
infection,  is  the  best  that  can  be  done.  As  a  rule,  the  onset  is  more  in- 
sidious than  in  the  other  forms  of  pelvic  inflammatory  disease,  and,  as 
has  been  stated,  these  symptoms  are  often  overshadowed  by  those  pro- 
duced by  the  primary  lesion.  Von  Franque  relates  instances  in  which  the 
first  symptom  has  been  sterility,  and  warns  against  treating  women  in 
general  for  this  symptom,  without  first  excluding  this  form  of  infection. 
In  the  case  of  the  gonococcal  type  of  infection,  the  fact  that  the  patient 
is  a  married  woman  or  one  of  loose  morals,  and  the  evidence  of  gonorrhea 
in  the  lower  genital  tract  are  points  which  put  the  examiner  on  his  guard 
for  this  variety  of  infection.    In  the  case  of  streptococcus  or  staphylococ- 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES    205 

cus  infection  the  fact  that  these  usually  follow  the  emptying  of  a  preg- 
nant uterus,  whether  at  or  before  term,  or  succeed  some  intra-uterine 
manipulation,  the  sudden  onset,  the  high  temperature,  the  severity  of 
attack  in  general,  are  suggestive  of  these  organisms.  In  a  definite  pro- 
portion of  patients  the  incumbents  of  tuberculous  salpingitis,  none  of 
these  symptoms  are  present,  and  this  fact  in  itself  is  very  suggestive  of  a 
tuberculous  infection.  A  history  of  pleurisy  and  susceptibility  to  bron- 
chitis is  always  suggestive  of  this  form  of  infection.  A  definite  pro- 
portion of  cases  is  secondary  to  tuberculous  peritonitis  or  to  osseous 
lesions.  Enlarged  lymphatic  glands  in  the  neck  are  present  in  some 
patients.  Indeed  the  presence  of  tuberculosis  in  any  other  portion  of 
the  body  is  suggestive.  In  a  certain  percentage  of  cases,  however,  no 
evidence  of  the  primary  focus  is  present.  It  should  also  be  borne  in  mind 
that  tuberculosis  is  one  of  the  most  frequent  forms  of  infection,  and  be- 
cause a  woman  has  a  tuberculous  pulmonary  lesion  this  does  not  prevent 
a  gonococcal  or  other  variety  of  pelvic  infection.  When  a  salpingitis 
occurs  in  a  virgin,  the  chances  are  largely  in  favor  of  its  being  tubercu- 
lous in  origin,  and  if,  in  addition,  the  disease  is  bilateral  and  associated 
with  a  demonstrable  primary  lesion,  such  as  a  pulmonary  tuberculosis, 
the  diagnosis  is  almost  certain.  The  existence  of  a  chronic  cough  should 
in  all  cases  put  the  examiner  on  his  guard  for  this  form  of  salpingitis. 

Tuberculous  salpingitis  may  occur  in  young  girls  and  children  before 
menstruation,  and  although  gonococcal  vulvovaginitis  in  rare  instances 
results  in  ascending  infection  involving  the  tubes,  it  is  comparatively  rare 
as  compared  to  tubal  lesions  in  children  caused  by  the  tubercle  bacillus. 
The  time  of  onset  of  the  initial  symptom  of  the  pelvic  trouble  is  also 
some  aid  in  determining  the  type  of  infection.  In  the  gonococcal  cases 
the  spread  to  the  body  of  the  uterus  and  to  the  tubes  nearly  always  fol- 
lows a  menstrual  period  and  less  frequently  the  emptying  of  a  pregnant 
uterus  or  intra-uterine  manipulation,  whereas  in  tuberculosis  this  is  not 
commonly  the  case.  Furthermore,  tuberculosis  of  the  tubes  tends  to  be 
somewhat  less  acute  and  painful  as  a  general  rule  than  does  the  Neisse- 
rian  infection.  The  fact  that  tuberculous  salpingitis  is  distinctly  less 
amenable  to  local  and  general  treatment,  such  as  copious  hot  douches, 
rest  in  bed,  and  the  regulation  of  the  bowels,  is  worthy  of  note  and  is  also 
a  suggestive  point. 

From  appendicitis  the  disease  can  usually  be  readily  differentiated 
by  its  bilateral  involvement,  the  presence  of  a  primary  focus,  its  pain 
low  in  the  abdomen,  the  induration  of  the  broad  ligament,  the  presence 
of  adnexal  lesions  as  determined  by  palpation,  the  absence  of  marked 
tenderness  over  McBurney's  point,  and  the  absence  of  a  history  of  in- 


206        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

discretion  in  diet,  etc.  So  also  the  history  and  finding  on  examination 
differ  quite  markedly  from  those  usually  observed  in  tubal  pregnancy. 

In  4  of  ii  cases  examined,  the  author  has  been  able  to  demonstrate 
tubercle  bacilli  in  the  leukorrheal  discharge.  Cummh.s  53  has  reported 
good  results  by  this  method.  He  is  careful  to  obtain  the  secretion  for 
examination  from  the  depths  of  the  cervical  canal,  as  an  additional  safe- 
guard in  eliminating  the  smegma  bacillus.  The  endometrium  is  at  least 
partly  involved  in  many  cases  of  advanced  tubal  tuberculosis.  In  these 
cases,  therefore,  it  is  only  a  matter  of  persistence  to  find  the  tubercle 
bacillus  in  the  discharge.  Care  must  necessarily  be  observed  to  exclude 
the  smegma  bacillus.  Meyer-Rugg  54  is  of  the  opinion  that  only  in  ex- 
ceptional cases  are  bacilli  found  in  the  secretion.  Orthmann  55  has  been 
able  to  demonstrate  tubercle  bacilli  in  42  per  cent  of  cases.  Doubtless 
animal  inoculation,  if  carefully  carried  out,  would  prove  of  value  in  this 
connection,  but  the  time  required  for  such  diagnostic  methods  is  a  dis- 
tinct drawback,  and,  as  the  treatment  is  likely  to  be  operative,  no  matter 
what  form  of  infection  is  present,  this  nullifies  the  value  of  the  method. 
The  examination  of  the  discharge  by  staining  methods  is  naturally  only 
of  value  in  positive  cases,  the  failure  to  demonstrate  this  organism  by  no 
means  excluding  the  presence  of  tuberculosis.  Hohne  56  has  advocated 
evacuations  of  pelvic  fluid  by  puncture  and  animal  inoculation  of  the 
material  thus  obtained.  This  procedure  may  be  of  value  in  certain  cases, 
but  certainly  is  not  advisable  as  a  routine  diagnostic  method.  Undoubt- 
edly valuable  information  may  be  obtained  by  the  examination  of  such 
material,  when  the  operation  of  vaginal  incision  is  indicated  from  a 
clinical  standpoint.  Sellheim  24  recommends  the  histologic  examination 
of  portions  of  the  uterine  mucosa  for  evidence  of  tuberculosis. 

Tuberculin  has  been  employed  as  an  aid  to  the  diagnosis.  Pankow  57 
states  that  he  observed  a  focal  reaction  in  three  cases  of  non-tuberculous 
pelvic  inflammatory  disease,  but  that  in  one  of  these  the  reaction  may 
have  been  caused  by  menstruation.  Sahli  58  has  emphasized  the  point 
that  the  sensitiveness  to  tuberculin  is  increased  for  a  few  days  prior  to 
menstruation.  Beer  59  states  that  focal  reaction  in  the  absence  of  tuber- 
culosis is  exceptional.  Mohr  60  is  of  the  opinion  that  a  negative  response 
excludes  tuberculosis,  but  Beer  thinks  a  general  plus  and  a  focal  response 
is  practically  invariably  due  to  a  focal  tuberculosis,  and  such  a  response 
locates  the  diseased  area.  A  general  minus  focal  response  is  of  no  prac- 
tical value,  as  the  most  careful  examination  cannot  positively  exclude  a 
tuberculous  focus  in  other  parts  of  the  body,  which  may  give  the  general 
reaction.  Tuberculin  should  not  be  employed  at  or  near  the  menstrual 
period. 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES     207 

Differential  Diagnosis  Between  Tuberculous,  Gonococcal  and 
Streptococcal  Pelvic  Inflammatory  Disease 


Tuberculous 

Gonococcal 

Streptococcal 

1.  Often   a    family   history 
of      tuberculosis ;      25 
per  cent  (Lock61). 

1.  Family  history  of  tuber- 
culosis incidental. 

1.  Family  history  of  tuber- 
culosis  incidental. 

2.  Any  age,  although  most 
frequent    between    20 
and     35.       The     most 
frequent      cause      for 
pelvic       inflammatory 
disease   in  childhood. 

2.  Most     frequent     during 
active       sexual       life. 
Rare  at  other  times. 

2.  Most  frequent  during 
active  sexual  life. 
Rare  at  other  times. 

3.  Rarely  primary.    Nearly 
always   a   primary   le- 
sion elsewhere  in  the 
body.     The  latter  may 
be   quiescent  or   reso- 
lution   may    have    oc- 
curred.     Close    ques- 
tioning     will      nearly 
always     elicit     history 
pointing    towards   tu- 
berculosis     in     other 
parts   of   the   body;   a 
history    of    lung,    in- 
testinal,         peritoneal, 
bone   or  joint   disease 
very  suggestive. 

3.  No   history   of   tubercu- 
losis elsewhere  in  the 
body.      (In    this    con- 
nection it  must  be  re- 
membered that  tuber- 
culosis is  an  extreme- 
ly     frequent      disease 
and  that  persons  suf- 
fering from  it  are  by 
no  means   immune  to 
other  forms  of  pelvic 
infection.)       If     pres- 
ent, it  is  incidental. 

3.  No  history  of  tubercu- 
losis elsewhere  in  the 
body.  If  present,  it 
is  incidental. 

4.  General      health      often 
impaired    as    a    result 
of  primary  lesions. 

4.  General  health  good  ex- 
cept   as    impaired    by 
pelvic  lesions. 

4.  General  health  good 
prior  to  onset  of  pel- 
vic infection. 

5.  Relatively    as     frequent 
in    the    virgin    as    in 
those   in  whom   deflo- 
ration has  occurred. 

5.  Extremely    rare   in    vir- 
gins. 

5.  Extremely  rare  in  vir- 
gins. 

6.  Onset    of    pelvic    attack 
often     between     men- 
strual periods. 

6.  Pelvic      attack      usually 
follows     a     menstrual 
period    and    less    fre- 
quently   the    emptying 
of    a   pregnant   uterus 
or    intra-uterine    ma- 
nipulation. 

6.  Pelvic  attack  nearly  al- 
ways follows  the 
emptying  of  a  preg- 
nant uterus  or  intra- 
uterine manipulation 
of  the  pregnant  or 
parturient  uterus. 

7.  Generally  a  gradual  in- 
sidious   onset. 

Previous          history 
pointing     to     primary 
lesion    in    other    part 
of  the  body. 

7.  Onset  more  severe  than 
in      the      tuberculous. 
Previous     history     of 
leukorrhea,    urethritis, 
and  bartholinitis. 

7.  Onset  severe  and  evolu- 
tion of  symptoms 
rapid.  Often  intro- 
duced by  a  chill  fol- 
lowed by  hyperpyrexia. 
Usually  a  history  of 
pregnancy  and  intra- 
uterine  manipulation. 

208        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 


Tuberculous 


8.  Temperature  not  as  a 
rule  high,  and  in  ex- 
ceptional cases  may 
be  normal.  Slight 
evening  rise  of  0.5  or 
1  degree.  Fever  of- 
ten .  continues  over 
long  periods. 


9.  Pulse    in    proportion    to 
temperature. 


10.  Respiration  often  af- 
fected as  a  result  of 
the  primary  lung  le- 
sion. 


11.  Menstrual  disturbances 
frequently  antedate 
pelvic  symptoms. 
Scanty  menstruation 
or  even  amenorrhea 
not  infrequent. 


12.  Sterility  frequent.  (Dis- 
ease is  usually  bilat- 
eral.) 


13.  Pelvic  pain  less.  Onset 
often  masked  by 
symptoms  of  the 
primary   infection. 


14.     Pain     and     tenderness 
usually  bilateral. 


15.  Primary  lesion  else- 
where in  the  body. 
No  bartholinitis,  ure- 
thritis, or  cervicitis. 


10.  The  first  portion  of  the 
genital  tract  attacked 
is  the  tubes,  the  en- 
dometrium being  sub- 
sequently invaded.  In 
other  words,  genital 
tuberculosis  is  a  de- 
scending infection,  so 
that  bilateral  symp- 
toms antedate  leukor- 
rhea  and  other  symp- 
toms  of   endometritis. 


Gonococcal 


8.  Fever  of  ioo°-io2° 
usually  during  attack, 
generally  continues  5 
to  10  days,  and  is  fol- 
lowed by  a  period  of 
normal  temperature. 


9.  Pulse  in  proportion  with 
or  lower  than  would 
be  expected  with  the 
temperature. 


10.  Respiration     in     propor- 
tion with  temperature. 


11.  Menstrual  disturbances 
follow  pelvic  infec- 
tion. Flow  usually 
increased. 


12.  Sterility  frequent,  but 
often  follows  preg- 
nancy. (The  so-called 
one  child  sterility.) 


13.  Pain  more  marked  fea- 
ture. 


14.  Often  more  or  less  lo- 
calized to  one  or 
other  ovarian  region 
and  becomes  bilateral 
in  later  stages. 


15.  Evidence  of  gonorrhea 
in  lower  genital  tract. 
Leukorrhea  always 
present,  usually  yel- 
low and  purulent  or 
mucopurulent. 


16.  Is  an  ascending  infec- 
tion. First  the  lower 
genital  tract,  then  the 
mucosa  of  the  body 
of  the  uterus,  and 
from  thence  the  ad- 
nexa,  so  that  leukor- 
rhea and  urethritis, 
etc.,  antedate  the  pel- 
vic symptoms. 


Streptococcal 


Hyperpyrexia,     I0i°- 
105°  F. 


9.  Pulse  rapid  and  often 
out  of  proportion 
with  fever.  Often  of 
bad   quality. 


10.  Respiration    in    propor- 
tion with  temperature. 


11.  Menstrual  disturbances, 
if  present,  follow  pel- 
vic infection. 


12.  Sterility  relatively  in- 
frequent. Disease 
chiefly  attacks  cellular 
tissue  of  broad  liga- 
ments. 


13.  Pain  more  marked. 


14.  May  be  either  unilateral 
or  bilateral. 


15.  No  gonorrhea,  but  evi- 
dences of  recent  preg- 
nancy. Leukorrhea 
usually  present  and 
often  thin  and  watery. 


16.  Sudden  onset  and  rap- 
id involvement  of 
ovarian  structures.  In- 
fection gains  access 
through  cervix  or 
uterus. 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES     209 


Tuberculous 


17.  Tubercle  bacilli  may  be 
demonstrated  in  the 
leukorrhea.  (Nega- 
tive findings  do  not 
exclude    tuberculosis.) 


18.  Cervix  normal. 


19.  Uterus  normal  in  size 
and  consistency. 
Slight  symmetrical  en- 
largement is  however 
not  rare. 


20.  Cellulitis  not  marked. 
Primary  pelvic  infec- 
tion in  tube. 


21.  Nearly   always   bilateral. 


22.  Palpable  lesions  of  the 
tubes  are  in  the.  nor- 
mal location  of  these 
organs,  unless  the 
tubes  have  prolapsed 
into  Douglas'  pouch, 
etc. 


23.  Tubes  sometimes  nodu- 
lar, and  this  charac- 
teristic may  sometimes 
be  demonstrated  by 
bimanual  examina- 
tion. 


24.  Both  ovaries  likely  to 
be  adherent,  but 
marked  enlargement 
not  frequent. 


25.  A  small  but  demon- 
strable amount  of 
free  fluid  in  peritoneal 
cavity  often  present 
during  height  of  at- 
tack. 


Gonococcal 


17.  Gonococci  may  be  dem- 
onstrated. (Nega- 
tive findings,  unless 
frequent  and  careful- 
ly performed,  do  not 
exclude  gonorrhea, 
especially  in  the 
chronic  stage.)  Gon- 
ococci usually  readily 
demonstrated  in  the 
acute  stage. 


18.  Cervix,  reddened  area 
surrounding  the  ex- 
ternal  OS. 


19.  Normal      or      somewhat 
enlarged. 


20.  Cellulitis  not  marked. 
Infection  chiefly  in 
tube. 


21.  Often  unilateral,  es- 
pecially in  the  early 
stages   of   the  disease. 


22.  Palpable  lesions  of  the 
tubes  are  in  the  nor- 
mal location  of  these 
organs,  unless  the 
tubes  have  prolapsed 
into  Douglas'  pouch, 
etc. 


23.  Nodular  character  of 
tubes  less  frequent. 
Often  sausage  shaped. 
A  small  adherent  ov- 
ary may  however  sim- 
ulate  nodule. 


24.  One  or  both  ovaries 
may  be  adherent.  En- 
largements more  fre- 
quent than  in  tuber- 
culosis. 


2^.  No  free  demonstrable 
fluid.  Disease  chiefly 
limited  to  pelvis. 


Streptococcal 


17.  Streptococci  may  b: 
demonstrated.  No  tu- 
bercle bacilli  or  gon- 
ococci present. 


Cervix,  softened,  patu- 
lous, and  often  ex- 
hibits evidence  of  re- 
cent pregnancy. 


19.  Usually    enlarged    (sub- 
involution). 


20.  Broad  ligament  chiefly 
involved.  Tubes,  if 
diseased,  are  second- 
arily so. 


May  be  either  unilateral 
or  bilateral. 


Chief  lesions  are  lower 
in  pelvis  than  either 
of  the  other  forms. 
Base  of  broad  liga- 
ment nearly  alwa;.  - 
thickened  and  tender 
and  firmer  than  nor- 
mal. Cervix  fixed 
and  attempt  to  move 
it  causes  marked  pain. 


Tubes  not  nodular,  of- 
ten soft  and  edema- 
tous. 


24.  One  or  both  ovaries  of- 
ten enlarged  and  seat 
of  adhesions  or  ab- 
scesses. 


25.  A  well  marked  general 
peritonitis  may  result. 
In  other  cases  no 
demonstrable  free 

fluid     is     present     m 
peritoneal  cavity. 


2io         GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 


Tuberculous 


26.  May  be  positive  for  va- 
rious  tuberculin   tests. 


27.  Leukocytes     normal     in 

number  or  leukocyto- 
sis not  marked  (ex- 
cepting where  large 
collections  of  pus  are 
present,  where  mixed 
infection  has  oc- 
curred). 


Gonococcal 


26.  May  be  positive  for  gon- 
ococcal complement 
fixation  test. 


27.  Leukocytosis   during 
acute  attack. 


the 


28.  A  well  marked  anemia, 
often  as  a  result  of 
the  primary  lesion, 
often    present. 


29.  No  organism  in  the 
blood  of  the  general 
circulation. 


30.  Runs  a  slow  prolonged 
course.  If  death  oc- 
curs, it  is  usually  due 
to  tuberculous  lesions 
other  than  of  the 
genital  tract. 


31.  Resistant  to  palliative 
treatment  as  usually 
applied  to  cases  of 
pelvic  inflammatory 
disease. 


2,2.  In  a   definite   proportion   32.  General    peritonitis     ex 


of  cases  results  in,  or 
is  followed  after 
weeks  or  months  by, 
a  general  tuberculous 
peritonitis. 


28.  Hemoglobin  varying 

with  stage  of  disease 
and  individual  case. 
Less  marked  anemia 
than  in  tuberculosis. 


Streptococcal 


26.  Unless  tuberculosis  or 
gonorrhea  is  present 
in  conjunction  with 
the  streptococcic  in- 
fection, the  foregoing 
tests  are  negative. 


27.  Well  marked  leukocyto- 
sis   usually   present. 


29.  No  organism  in  the 
blood  of  the  general 
circulation. 


30.  Acute  attack  usually 
lasts  from  5-10  days, 
continuing  at  varying 
intervals  over  period 
of  years.  More  or 
less  invalidism.  Rarely 
terminating   fatally. 


31.  Palliative  treatment 

nearly  always  results 
in  at  least  temporary 
improvement. 


tremely  rare. 


28.  Anemia     often     marked, 


especially 
stages. 


late 


29.  Blood        cultures 
quently  positive. 


fre- 


30.  Sharp  acute  course, 
usually  ending  in 
complete  recovery  or 
death. 


31.  Palliative   treatment  of- 
ten   eurative. 


32.  If  general  peritonitis  oc- 
curs, is  of  an  acute 
severe  type  and  orcurs 
during  the  course  of 
the  pelvic  infection. 


Prognosis. — In  considering  the  prognosis  it  must  be  remembered 
that  in  the  great  majority  of  cases  the  genital  infection  is  secondary. 
The  primary  lesion  must,  therefore,  be  as  thoroughly  studied  as  the 
pelvic,  and  is  usually  of  grave  importance.  Statistics,  moreover,  unless 
from  a  large  series  of  cases,  and  compiled  with  extreme  care  regarding 
the  extent  and  location  of  the  primary  lesion,  are  apt  to  be  misleading. 
Indeed  so  many  factors  enter  into  the  question  of  a  prognosis  that  ordi- 
nary statistics  are  practically  valueless.  All  the  points  of  the  case  must 
be  carefully  studied  and  the  prognosis  based  upon  the  findings  in  the 
individual  patient.    The  age  of  the  patient,  the  duration,  course,  character, 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES     211 

extent,  individual  disposition,  the  social  and  financial  standing  of  the 
patient,  are  all  points  which  must  be  considered,  both  as  regards  the  course 
of  the  primary  as  well  as  of  the  genital  condition.  Mayer  9  is  of  the 
opinion  that  the  presence  of  high  fever  before  operation  is  an  extremely 
unfavorable  sign.  Fever,  either  the  result  of  a  primary  or  of  the  pelvic 
lesion,  is  undoubtedly  an  unfavorable  sign,  and  is  generally  an  indication 
for  delay  in  operative  intervention.  Of  22  cases  of  tubal  tuberculosis — > 
in  none  of  which  was  there  a  general  peritoneal  involvement,  all  of  which 
were  operated  upon  at  least  3  years  prior  to  our  study,  while  some  of 
them  had  been  operated  upon  12  years  ago,  and  all  were  traceable — 16 
are  alive.  About  2/3  of  this  series  of  cases  were  ward  patients  and  are 
therefore  presumably  unable  to  follow  out  an  ideal  course  of  postoperative 
hygienic  treatment. 

Baisch  51  states  that,  of  no  cases  of  tuberculosis  of  the  peritoneum 
or  genital  organs  occurring  at  the  University  of  Tubingen  during  the 
ten  years  prior  to  his  report,  40  died  within  four  years  after  treatment ; 
there  were  no  recurrences  after  this  period.  Five-sixths  of  the  fatal 
cases  died  during  the  first  year.  Of  55  cases  of  tuberculous  salpingitis, 
13  cases  were  not  operated  upon;  of  these  8  died,  in  4  the  general  condi- 
tion was  too  grave  to  warrant  operation,  and  in  4  others  pulmonary 
lesions  were  advanced.  Five  improved  under  expectant  treatment,  but 
only  1  was  cured.  Of  32  patients  treated  surgically,  9  died,  3  from 
peritonitis  following  injury  to  the  rectum,  1  from  bronchopneumonia; 
5  died  after  leaving  the  hospital,  one  from  pulmonary  tuberculosis;  13 
cases  were  cured.  In  6  new  inflammatory  tumors  appeared.  The  per- 
centage of  recurrence  was  highest  in  those  patients  in  whom  only  one 
tube  was  removed,  the  other  appearing  normal  at  the  time  of  the  operation. 

Evens  35  has  reported  a  series  of  23  cases  of  adnexal  tuberculosis, 
in  which  conservative  operations  were  performed  when  possible,  and  the 
uterus  removed  only  for  special  indications.  There  were  2  postoperative 
deaths,  1  from  postoperative  hematemesis  and  1  from  septic  nephritis ; 
16  of  the  remainder  were  traced  and  did  well;  in  3  there  was  good 
operative  recovery,  but  they  were  subsequently  lost  sight  of.  One  patient 
died  one  year  after  operation  from  the  primary  lesion,  and  one  case 
required  a  second  operation  for  the  removal  of  a  previously  conserved 
tube. 

Ollivier  62  has  recorded  the  histories  of  a  series  of  1 16  cases  of  genital 
tuberculosis.  Of  these  there  were  9  operative  deaths,  8  died  later  on, 
19  were  lost  sight  of  and  80  were  alive  at  the  time  of  the  report,  some 
as  long  as  10  years  after  the  operation. 

Bovis  and  Olow  63  report  the  histories  of  55  cases.     One  died  shortly 


212        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

after  operation  and  3  others  within  18  months;  43  of  the  series  were 
able  to  work  1  to  15  years  after  operation.  Mannheimer  64  reported  a 
series  of  22  cases  operated  upon,  with  1  death.  Twenty  of  these  patients 
were  followed  subsequently  and  it  was  found  1  had  died  of  pulmonary 
tuberculosis,  and  1  was  ill  from  the  same  cause.  Eight  of  these  22  pa- 
tients died  within  5  years  of  pulmonary  tuberculosis.  Lindquist,  at  the 
same  meeting,  records  the  results  of  operation  in  20  cases.  Of  these 
there  were  14  normal  recoveries,  and  6  left  the  hospital  with  fistulas — no 
operative  mortality.  Frolich  at  the  same  time  reports  50  cases,  2  operative 
deaths  and  2  who  died  subsequently ;  13  were  improved,  29  were  well,  and 
4  untraced.  Kronig  65  believes  the  prognosis  in  genital  tuberculosis  should 
be  extremely  guarded.  Geist 66  reports  28  cases  with  3  operative  deaths. 
There  were  2  deaths  subsequently,  due  to  pulmonary  tuberculosis.  A 
number  of  fistulae  developed  and  the  average  stay  of  these  patients  in 
hospital  was  6  weeks;  13  of  the  patients  were  discharged  from  the 
hospital  well,  and  12  improved. 

Schlimpert  67  states  that,  in  2,173  postmortem  examinations  upon 
tuberculous  individuals,  73,  or  3.5  per  cent,  had  some  form  of  genital 
involvement.  Simmonds,20  in  6,000  postmortems  upon  women,  found  the 
genital  organ  involved  in  1.33  per  cent.  In  none  of  Schlimpert' s  or 
Simmonds'  subjects  was  the  genital  tuberculosis  the  cause  of  death,  and 
in  only  3  cases  did  the  subjects  come  to  the  mortuary  from  gynecological 
wards.  Although  undoubtedly  the  genital  lesions  are  of  secondary  im- 
portance in  comparison  with  the  tuberculous  foci  in  other  parts  of  the 
body,  the  author's  experience  does  not  by  any  means  bear  out  the  result 
of  Schlimpert  and  Simmonds,  as  severe  and  even  fatal  lesions  have  been 
observed  by  him  in  a  considerably  higher  proportion  than  found  in  the 
statistics  above  quoted.  This  is  undoubtedly  due  to  the  character  of 
the  material  from  which  the  observations  have  been  made. 

Desgouttes  and  Ollivier 68  believe  that  intestinal  lesions,  particularly 
those  of  the  small  intestine,  have  an  especially  unfavorable  bearing  upon 
the  prognosis  in  cases  of  tuberculous  adnexitis.  These  authors  state 
that  the  prognosis  depends  very  largely  on  the  extent  to  which  the  intes- 
tines have  become  involved.  When  there  are  no  intestinal  adhesions, 
the  operation  is  comparatively  simple  and  safe.  When  only  the  large 
intestines  are  involved,  all  adhesions,  both  of  the  pelvic  organs  and 
peritoneum,  should  be  freed  with  the  greatest  care.  When  the  small 
intestines  are  involved,  the  prognosis  becomes  less  favorable. 

The  operative  mortality  from  the  operation  per  se  in  properly  selected 
cases  of  tuberculous  salpingitis  is  not  greater  than  in  other  chronic  tubal 
infections.     The   fact  that  pulmonary  lesions   are   often  present  does, 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES-    213 

however,  markedly  increase  the  operative  risks.  The  subject  of  anesthesia 
and  surgical  intervention  in  general  in  phthisical  individuals  will  be 
considered  in  a  subsequent  chapter.  The  most  favorable  results  are  ob- 
tained in  those  cases  in  which  it  is  possible  to  remove  the  entire  intra- 
peritoneal   focus    of    the    infection. 

All  these  patients  exhibit  a  tendency  to  continue  subacute  or  chronic 
symptoms  despite  palliative  treatment,  and  the  dangers  of  a  subsequent 
general  peritonitis  are  always  present.  The  tendency  to  resist  palliative 
treatment  is  a  sign  of  considerable  diagnostic  value  and  is  a  point  which 
has  not  been  sufficiently  emphasized. 

When  an  ordinary  case  of  pelvic  inflammatory  disease  is  observed 
which  does  not  show  improvement  under  palliative  treatment,  a  tuber- 
culous origin  should  be  suspected.  It  is  true  that  many  tuberculous 
patients  do  show  improvement,  but  the  proportion  is  smaller  than  in 
the  commoner  varieties  of  adnexitis.  The  simple  evacuation  of  a  pelvic 
abscess  is  much  less  favorable  than  when  the  entire  intraperitoneal  focus 
of  infection  can  be  removed,  and  nearly  always  a  more  prolonged  con- 
valescence may  be  expected  in  cases  of  tuberculous  origin  than  in  those 
of  other  forms  of  pelvic  infection.  In  such  cases  chronic  fistulas  are 
prone  to  result.  Indeed,  Hannes  69  is  of  the  opinion  that  vaginal  incision 
is  of  little  or  no  value  in  the  case  of  tuberculous  pelvic  inflammatory 
disease. 

The  final  outcome  of  operative  cases  after  leaving  the  hospital  is 
less  favorable  in  tuberculous  cases  than  in  those  due  to  other  varieties 
of  microorganisms.  First,  these  patients  must  face  the  dangers  of  the 
primary  lesion,  the  possibilities  of  the  development  of  a  general  or  local 
tuberculous  peritonitis,  the  former  being  a  not  infrequent  result,  as  well 
as  the  development  of  new  secondary  lesions.  The  dangers  of  local  recur- 
rence are  especially  great  in  those  cases  in  which  tubercles  are  observed 
in  the  peritoneal  cavity  which  are  not  removable  at  operation,  and  in  those 
cases  in  which  one  tube  only  is  excised.  In  our  laboratory  tuberculosis 
has  been  demonstrated  in  every  specimen  of  macroscopically  normal  tube 
removed  in  conjunction  with  tuberculous  salpingitis  of  the  opposite  side. 
It  should  not  be  inferred  from  this  that  every  case  is  bilateral,  but  there 
is  evidence  to  show  that  this  infection  is  usually  bilateral,  even  when  one 
of  the  tubes  is  macroscopically  normal,  and  the  leaving  of  such  a  tube 
certainly  increases  the  risks  of  a  local  recurrence  and  also  for  the  develop- 
ment of  a  general  tuberculous  peritonitis.  Mayer-Rugg 54  is  of  the 
opinion  that  genital  tuberculosis  is  rarely  the  developing  point  for  a 
tuberculous  peritonitis.  As  has  been  stated,  however,  in  a  certain  pro- 
portion of  cases  studied  by  the  author,  a  general  peritonitis  has  developed, 


214        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

so  that  we  feel  that  this  complication  must  be  considered.  Albrecht  and 
Schlimpert 1  found  that,  in  a  series  of  cases  of  general  tuberculous  peri- 
tonitis occurring  in  women,  12  per  cent  originated  in  the  genital  tract. 
The  possibility  of  a  general  miliary  tuberculosis  developing  subsequent 
to  operation  must  also  be  considered.  In  our  series  of  cases  this  has 
never  developed.  A  study  of  the  literature  of  this  subject  shows  that 
such  a  complication  may  take  place  and  is  most  prone  to  occur  after 
operating  upon  acute  cases.  Excluding  the  operative  mortality,  the  great 
majority  of  fatal  cases  occur  in  the  first  year. 

Treatment. — The  question  of  the  form  of  treatment  to  be  employed 
for  cases  of  tuberculosis  of  the  adnexa  is  still  somewhat  in  doubt.  No 
rule  of  thumb  can  be  formulated,  and  each  case  must  be  judged  indi- 
vidually. Whether  operative  intervention  or  palliative  treatment  will 
give  the  best  results  can  only  be  decided  after  studying  the  particular 
case.  At  the  risk  of  repetition,  it  must  be  emphasized  that  these  cases 
are  usually  secondary,  and  therefore  the  condition  of  the  primary  lesion 
is  of  the  utmost  importance. 

All  patients,  the  incumbents  of  pelvic  inflammatory  disease  in  which 
a  tuberculous  origin  is  suspected,  should  be  subjected  to  an  extremely 
rigid  physical  examination,  in  which  the  entire  body  should  be  carefully 
studied.  According  to  von  Franque,  renal  tuberculosis  is  comparatively 
infrequent  as  an  accompaniment  of  tuberculous  salpingitis;  however,  this 
complication  was  present  in  one  of  our  cases,  and  we  believe  the  kidneys 
should  be  carefully  investigated  in  all  cases,  and  that  a  cystoscopic  exam- 
ination is  indicated  in  all ;  and,  should  any  doubt  exist,  the  ureters  should 
be  catheterized.  Fortunately,  renal  tuberculosis  in  combination  with 
genital  lesions  is  less  frequent  in  women  than  in  men. 

Although  primary  cases  of  tuberculous  pelvic  inflammatory  disease 
do  occur,  they  are  so  rare  and  the  difficulty  in  making  such  a  diagnosis 
is  so  great  that  for  practical  purposes  it  is  safe  to  regard  all  cases  as 
secondary,  and  so  treat  them.  As  actually  observed,  cases  of  tuberculous 
adnexitis  may  be  divided  into  three  (3)  classes — 1st,  those  in  which  there 
is  an  active  primary  lesion ;  2nd,  those  in  which  there  is  a  demonstrable 
but  non-active  primary  lesion ;  and  3rd,  those  in  which  no  primary  lesion 
can  be  diagnosed  with  certainty.  Class  1  comprises  those  cases  in  which 
there  is  an  active  primary  lesion,  and  should  not,  as  a  rule,  be  submitted  to 
operation,  the  exception  being  patients  in  whom  some  palliative  operation 
is  performed  to  relieve  pain  or  other  symptoms,  such,  for  example,  as 
the  vaginal  incision  for  the  evacuation  of  pus  in  a  large  pelvic  abscess. 
Extensive  operations  should  certainly  never  be  performed.  Under  proper 
hygienic  and  other  treatment,  the  primary  lesion  may  improve  and  the 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES     215 

case  may  eventually  come  under  the  heading  of  class  2.  Operations 
during  the  acute  stage  of  the  primary  lesions  are  doubly  hazardous, 
because  of  the  dangers  of  dissemination  of  the  infection  by  the  actual 
operative  procedure  and  the  lessened  resistance  exhibited  by  those  patients. 
General  anesthetics  are  contra-indicated  in  the  presence  of  active  pulmon- 
ary lesions.  Spinal  anesthesia  may  be  necessary  in  some  of  these  cases. 
Minor  and  even  certain  major  operations  may  in  some  cases  be  performed 
under  local  anesthesia,  but  the  general  rule  to  be  adopted  in  cases  in 
which  there  is  an  active  primary  lesion  is  non-operative  interference,  and 
this  is  particularly  true  when  the  primary  lesion  is  in  the  lung.  Proper 
hygienic  and  medicinal  treatment  is  the  course  to  be  recommended  for 
this  class  of  patients,  together  with  appropriate  measures  indicated, 
directed  towards  the  pelvic  condition. 

Class  2  comprises  those  cases  in  which  the  greatest  difficulty  will  be 
encountered  in  deciding  the  best  form  of  treatment.  Here  each  case 
must  be  carefully  studied  individually.  It  must  be  remembered  that  the 
operative  risks  in  these  patients  is  much  greater  than  in  the  ordinary 
patient.  The  chief  points  to  be  considered  are  the  extent  and  character 
of  the  primary  lesion  and  the  actual  danger  to  the  patient  from  the 
genital  lesion,  the  amount  of  discomfort  produced  by  the  latter,  and  the 
type  of  operation  required  to  alleviate  or  cure  the  disease  of  the  genitalia. 
As  has  been  elsewhere  stated,  the  subject  of  anesthesia  in  tuberculous 
patients  will  be  considered  in  detail  in  a  subsequent  chapter.  It  is  ob- 
viously a  very  important  one  in  these  cases.  Our  experience  has  been  that 
ether  anesthesia  for  patients  with  moderately  small  non-active  pulmonary 
lesions  has  not  proved  exceptionally  hazardous.  However,  this  danger  is 
a  real  one  and  must  be  considered.  Certainly  all  cases  belonging  to  this 
class  should  be  carefully  studied  for  a  considerable  period  of  time  before 
operative  intervention  is  decided  upon,  the  exception  to  this  being  when 
the  operation  required  is  of  a  life  saving  character  or  can  be  performed 
under  local  anesthesia. 

Class  3  will  generally  be  treated  as  ordinary  pelvic  inflammatory 
disease  and  the  diagnosis  of  the  tuberculous  origin  of  the  condition  will 
often  only  be  made  after  the  abdomen  is  opened,  or  in  the  laboratory 
when  the  histologic  specimens  are  examined.  All  patients  belonging  to 
this  class,  in  whom  tuberculosis  is  suspected,  as  for  example,  if  pelvic 
inflammatory  disease  be  diagnosed  in  a  virgin,  should  be  treated  as  if  they 
belonged  to  class  2,  and  every  precaution  to  prevent  an  exacerbation  of  a 
possibly  existing  primary  lesion  should  be  adopted. 

Little  has  been  said  regarding  spontaneous  cure  of  tuberculous  sal- 


216        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

pingitis.  This  undoubtedly  occasionally  occurs,  but  is  rare,  although 
partial  resolution  is  not  infrequent.  Beyond  question,  many  tuberculous 
women  suffer  from  mild  adnexal  lesions,  which  do  not  require  or  receive 
any  local  treatment,  and  which  subsequently  undergo  partial  resolution. 
This  is  amply  proven  by  a  study  of  postmortem  material  from  tuberculous 
women  in  whom  some  7  per  cent  show  evidence  of  salpingitis.  It  is 
true  some  of  these  may  not  have  been  of  tuberculous  origin,  but  even 
in  series  of  autopsies  verified  by  histologic  or  bacteriologic  examination, 
a  definite  proportion  of  tuberculous  tubal  lesions  is  found  in  women  in 
whom  they  were  unsuspected  during  life,  this  showing  that  in  these 
cases  the  symptoms  of  the  pelvic  disease  were  either  masked  by  those  of 
the  primary  lesion,  or  were  of  such  a  mild  character  that  attention  was  not 
directed  to  the  pelvic  condition.  At  present  doubtless  far  more  can  be 
accomplished  by  hygienic  and  general  measures  than  in  the  past,  and 
it  is  of  the  utmost  importance  that  all  tuberculous  patients  should  receive 
a  long  course  of  postoperative  care  and  observe  the  usual  rules  for  tuber- 
culous patients.  This  applies  to  all  classes  and  is  usually  best  carried  out 
in  a  sanatorium.  Out  door  life,  forced  feeding,  etc.,  are,  generally  speak- 
ing, of  utmost  importance,  and  are  quite  if  not  more  beneficial  to  the 
patient  who  has  been  suffering  from  a  tuberculous  pelvic  inflammatory 
disease  than  is  the  operation. 

A  preliminary  treatment  of  this  character  prior  to  the  operation  should 
also  be  advised  in  the  majority  of  cases,  certainly  in  all  cases  in  which 
the  pelvic  lesions  are  not  materially  depleting  the  strength  of  the  patient. 
Rollier  70  has  treated  700  patients  suffering  from  various  forms  of  sur- 
gical tuberculosis  by  exposure  to  the  sun's  ray  at  Leysin,  Sweden,  during 
the  past  9  years,  and  is  convinced  of  the  benefits  to  be  derived  from  this 
form  of  treatment.  He  keeps  his  patient  in  the  open  air  practically  all 
the  year. 

As  in  pelvic  lesions,  the  result  of  microorganism  other  than  tubercle 
bacillus,  operations  should  be  avoided  during  the  active  stage  of  the 
disease,  and  in  all  cases  the  patient  should  be  subjected  to  a  course  of 
preliminary  local  treatment  similar  to  that  now  generally  adopted  for 
non-tuberculous  pelvic  inflammatory  disease.  In  cases  of  pelvic  inflam- 
matory disease  of  tuberculous  origin  it  is  sometimes  difficult  to  determine 
if  fever  is  being  continued  by  the  primary  or  by  the  pelvic  lesion.  Prac- 
tically this  is  of  no  great  importance,  as  patients  should  not  as  a  rule 
be  subjected  to  operation  in  whom  hyperpyrexia  is  present.  The  local 
treatment  consists  of  rest  in  bed,  preferably  in  the  Fowler  position,  the 
regulation  of  the  bowels  by  means  of  mild  cathartics  or  enemata,  the 
application  of  heat  to  the  lower  abdomen,  and  the  employment  of  frequent, 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES    217 

copious,  hot  vaginal  irrigation.  Hofmeier,71  Bumm,36  and  Freund 72 
advise  cold  during  the  acute  stage.  The  application  of  heat  to  the  lower 
abdomen,  together  with  copious,  hot  douches  is  of  great  benefit  and 
tends  to  promote  absorption.  Heat  may  be  applied  by  means  of  hot  sand 
bags,  the  weight  being  regulated  to  suit  the  comfort  of  the  individual 
patient,  or  large  hot  poultices,  rubber  coils  containing  hot  water,  or  a 
hot  water  bag  may  be  employed.  An  electrically  heated  pad,  such  as 
can  be  procured  in  instrument  supply  stores,  is  the  best  means  of  applying 
heat  to  the  abdomen.  In  any  case  the  heat  should  be  applied  as  constantly 
as  possible,  a  temperature  of  no°  to  1200  F.  being  maintained.  A  good 
working  rule  in  this  respect  is  to  have  the  application  as  hot  as  can  be 
comfortably  borne  by  the  patient. 

Under  this  form  of  treatment,  combined  with  proper  feeding  and 
hygiene,  many  cases  will  improve,  and  in  a  small  proportion  no  operative 
treatment  will  be  required.  In  the  presence  of  extensive  pelvic  lesions 
of  doubtful  origin  it  has  been,  however,  the  author's  experience  that  cases 
O'f  tuberculous  adnexitis  are  less  susceptible  to  palliative  treatment  than 
any  other  form  of  pelvic  inflammatory  disease.  Indeed,  in  some  cases  in 
which  the  primary  lesions  have  been  quiescent  and  difficult  to  detect, 
the  continuance  of  the  acute  symptoms,  as  indicated  by  fever,  increased 
pulse  rate,  pelvic  pain,  etc.,  after  a  moderate  trial  of  the  palliative 
treatment,  has  been  the  first  symptom  which  has  suggested  the  correct 
diagnosis  of  the  cause  of  the  condition. 

Findley  is  a  strong  advocate  of  non-operative  measures  in  the  majority 
of  cases.  He  states  that  in  many  cases  the  symptom  complex  complained 
of  is  often  due  not  to  the  pelvic  lesion,  but  to  the  primary  lesion,  and  that 
tuberculosis  of  the  genital  organs  in  itself  rarely  causes  death.  Dysmenor- 
rhea is  frequently  the  result  of  pulmonary  tuberculosis.  The  general 
peritonitis  which  sometimes  follows  in  these  cases  is  not  necessarily  sec- 
ondary to  the  salpingitis,  but  may  result  from  a  hematogenous  infection 
from  the  primary  focus  in  the  lungs  or  elsewhere.  Findley  emphasizes 
the  facts  that  operation  may  awaken  a  latent  primary  focus  and  result 
in  a  general  dissemination  of  the  disease,  that  the  mortality  is  relatively 
high,  that  there  is  at  least  some  tendency  towards  self  limiting  of  the 
genital  lesions,  so  that  when  operation  is  necessary  it  should  be  as  con- 
servative as  possible,  especially  in  young  patients.  Patel  and  Ollivier  74 
have  reported  the  results  of  operations  on  121  patients,  all  of  whom 
were  operated  upon  since  1900.  In  their  series  the  abdominal  route 
was  more  satisfactory  than  was  the  vaginal.  As  the  result  of  their  obser- 
vations, they  believe  it  unwise  to  save  a  uterus,  if  the  ablation  of  the 
adnexa  is  necessary,  and,  on  the  whole,  favor  hysterectomy  with  bilateral 


218        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

salpingo-oophorectomy  in  the  majority  of  cases.  They  think  that  the 
artificial  menopause  induced  by  the  removal  of  both  ovaries  is  less  severe 
in  tuberculous  than  in  ordinary  patients.  Berkley's  75  studies  offer  further 
evidence  showing  the  advantages  to  be  derived  from  hysterectomy  in 
these  cases.  In  his  series  of  tuberculous  adnexitis  cases  the  uterus  was 
involved  in  29  per  cent,  and  von  Franque  76  found  a  similar  proportion. 
At  the  German  Congress  held  in  Munich  in  191 1  the  majority,  including 
Zweifel,  Stockel,  Gottschalk,  Menge,  Kiistner,  Fehling,  Opitz,  Wertheim, 
Startz,  and  Sarvey,  supported  operative  treatment  for  the  majority  of 
cases.  Sellheim  and  Herff  were  less  favorable  to  operation.  Sippel 
recommended  operation  when  conservative  treatment  failed.  Nearly  all 
warned  against  operation  during  the  acute  stage  of  the  pelvic  lesion,  and 
urged  that  a  thorough  search  for,  and  study  of,  the  primary  lesion  be 
made  prior  to  deciding  upon  the  course  of  treatment. 

Von  Franque  believes  that  the  majority  of  cases  of  genital  tubercu- 
losis should  be  operated  upon,  not  because  there  is  any  imminent  danger 
of  life,  except  in  exceptional  cases,  but  following  the  principle  which 
applies  to  all  forms  of  surgical  tuberculosis,  in  which  it  is  good  surgery 
to  remove  the  infected  focus  as  far  as  is  possible.  Medical  treatment,  he 
believes,  is  slow,  uncertain,  and  costly,  and  since  the  chief  function  of 
the  genital  organs  is  lost  at  any  rate,  it  seems  rational  to  remove  them 
in  order  to  prevent  a  further  spread  of  the  process.  In  66  per  cent  of 
the  cases  permanent  cures  can  be  obtained.  If  the  pelvic  lesions  are 
extensive,  von  Franque  recommends  a  radical  operation,  removing  the 
uterus  and  both  adnexa;  but  if  only  the  tubes  are  macroscopically  involved, 
a  bilateral  salpingectomy  is  performed,  leaving  the  uterus  and  ovaries. 
Murphy  7  also  recommends  operation  in  all  cases  of  tuberculous  salpingitis 
when  the  general  condition  does  not  contra-indicate  it.  He  advises 
sparing  the  ovaries  when  possible,  and  stigmatizes  the  routine  removal 
of  the  uterus  as  a  pernicious  practice.  Patel 33  states  that  patients  with 
tuberculous  salpingitis  as  a  rule  do  badly  if  not  operated  upon. 

Operative  Treatment. — Presuming  that  operative  interference  has 
been  decided  upon,  the  type  of  operation  to  be  performed  is  the  next  point 
to  be  considered.  Shall  the  operation  be  conservative  or  shall  the  entire 
uterus  and  adnexa  be  removed.  Much  depends  upon  this  point  and  many 
factors  enter  into  the  problem.  Like  similar  treatment  in  other  forms 
of  pelvic  inflammatory  disease,  no  hard  and  fast  rules  can  be  formulated 
regarding  this  point.  Our  first  object  is  to  cure  the  patient.  It  is  im- 
portant to  consider  what  structures  within  the  pelvis  are  diseased.  Statis- 
tics have  shown  that  in  over  90  per  cent  of  cases  of  pelvic  inflammatory 
disease,  the  tubes  are  involved.     In  the  series  of  30  cases  from  which  our 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES     219 

studies  have  been  made,  this  proportion  reached  100  per  cent.  In  the 
great  majority  of  cases  the  involvement  was  bilateral,  and  even  when  one 
tube  appeared  macroscopically  normal  or  only  showed  a  few  adhesions, 
histologic  examinations  usually  revealed  a  more  or  less  well  marked 
invasion.  Observers  have  shown  that  the  endometrium  is  involved 
in  about  20  to  30  per  cent  of  cases.  Extensive  involvement  of  the 
myometrium  is  comparatively  rare.  On  the  other  hand,  true  ovarian 
involvement  is  rather  infrequent,  although  peri-oophoritis  is  more  com- 
mon. Our  custom  is  to  conserve  the  uterus  and  one  or  both  ovaries  when 
possible. 

In  common  with  most  American  gynecologists,  we  favor  the  abdom- 
inal route  when  operating  upon  cases  of  pelvic  inflammatory  disease, 
the  single  exception  to  this  being  in  those  cases  in  which  pus  can  be 
evacuated  without  traversing  the  peritoneal  cavity,  as  in  the  case  of  an 
abscess  pointing  into  the  vagina.  In  the  case  of  tuberculosis  the  abdom- 
inal route  is  especially  to  be  desired,  as  a  close  inspection  of  the  pelvic 
organs  is  of  the  utmost  importance. 

Minto  77  has  performed  a  series  of  animal  experiments,  which  he 
believes  shows  that  oophorectomy  is  advisable.  In  these  tests  control 
animals  in  which  the  ovaries  were  not  removed  succumbed  in  all  cases 
earlier  than  did  those  in  whom  oophorectomy  was  performed.  Interesting 
as  this  series  of  experiments  was,  we  do  not  believe  that  the  results  are 
analogous,  or  should  be  applied  to  the  treatment  of  women.  The  author 
has  elsewhere  78  stated  at  length  the  advantages  of  ovarian  conservation 
when  these  structures  are  not  hopelessly  diseased.  The  fact  that,  in 
tuberculous  pelvic  inflammatory  diseases,  the  ovaries  are  rarely  actually 
invaded  by  the  tubercle  bacillus  is  added  reason  for  this  conservatism. 
Much  will  naturally  depend  upon  the  age  of  the  patient  and  other  circum- 
stances surrounding  the  individual  case.  The  case  is,  however,  exceptional 
where  at  least  one  ovary  cannot  be  safely  saved. 

Whether  one  or  both  tubes  should  be  removed  is  often  difficult  to 
determine.  Many  factors,  however,  point  to  the  advisability  of  bilateral 
salpingectomy  as  the  routine  procedure.  With  both  tubes  macroscopically 
diseased,  even  if  one  shows  nothing  more  than  adhesions,  we  believe  that 
both  should  be  removed.  When  one  tube  is  diseased  and  the  other  is 
macroscopically  normal,  histologic  examination  of  the  latter  often  shows 
it  to  be  the  seat  of  a  salpingitis.  For  this  reason,  a  general  radical  attitude 
regarding  the  routing  removal  of  both  tubes  in  cases  of  tuberculous  pelvic 
inflammatory  disease  is,  we  believe,  to  be  encouraged.  The  only  advan- 
tage in  tubal  conservation  is  to  prevent  sterilization.  The  advantages  of 
fertility  are  less  urgent  in  the  tuberculous  than  in  other  forms  of  infec- 


220        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

tion.  Tuberculous  endometritis  is  an  accompaniment  of  tuberculous 
salpingitis  in  about  20  or  30  per  cent  of  cases.  The  disease  exhibits 
a  tendency  to  especially  involve  the  endometrium  in  the  cornu  of  the 
uterus  and  to  limit  itself  to  areas  about  the  internal  os.  The  fact  that 
in  1  in  every  4  or  6  cases  there  is  endometrium  involvement  is  a  strong 
argument  in  favor  of  a  routine  supravaginal  hysterectomy.  On  the  other 
hand,  the  operative  mortality  due  to  the  prolongation  of  the  operation, 
and  the  actual  severity  of  the  procedure  is  somewhat  greater  in 
hysterectomy  than  in  bilateral  salpingectomy. 

After  the  abdomen  has  been  opened  the  same  operative  indications 
should  govern  the  surgeon  as  in  the  ordinary  inflammatory  case,  with  the 
exception  perhaps  that  greater  radicalism  as  regards  surgery  of  the  tubes 
is  indicated  in  this  form  of  infection. 

The  patient  is  sterilized  by  the  removal  of  the  tubes,  but  better 
conservative  surgery  can  be  performed  by  leaving  the  uterus,  as  the 
ovarian  blood  supply  is  less  likely  to  be  impaired.  This  is  an  extremely 
important  factor  in  ovarian  conservation;  so,  unless  the  uterus  is  macro- 
scopically  diseased,  its  conservation  is  advisable  for  this  as  well  as  for 
the  preservation  of  the  menstrual  function.  The  sterilization  of  these 
patients  in  those  cases  in  which  the  disease  has  not  already  accomplished 
this  result  is,  as  a  general  rule,  less  of  a  calamity  than  in  the  ordinary 
case  of  pelvic  inflammatory  disease,  as  pregnancy  in  the  tuberculous 
patient  is  unadvisable  in  most  cases  and  often  extremely  detrimental  to 
the  general  health  of  the  individual.  When  it  is  necessary  to  remove 
the  uterus,  a  supravaginal  hysterectomy  is  preferable  to  a  panhysterec- 
tomy provided  that  the  cervix  is  uninvolved.  In  a  previous  chapter  the 
rarity  of  cervical  tuberculosis  has  been  shown. 

Result  of  Operative  Treatment. — The  tendency  towards  the  forma- 
tion of  fistulae  of  divergent  varieties  is  greater  in  tuberculous  than 
in  non-tuberculous  patients,  and  for  this  reason  drainage  should  rarely 
be  employed.  The  immediate  operative  mortality  is  not  particularly  great 
in  properly  selected  cases,  but  the  end  results  are  less  favorable,  often 
owing  to  the  development  of  other  secondary  lesions  or  to  the  lighting  up 
of  the  primary  focus. 

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70.  Rollier.     Monschr.  f.  Kindhk.     1913.     11:  No.  8. 

71.  Hofmeier.     Deutsch.   Med.   Woch.      1909.     p.  2249. 

72.  Freund,  H.     Ther.  Montschr.      1911.     25:157. 
72>-  Findley,  P.     Med.  Her.      1913.     32:181. 

74.  Patel,  M.,  et  Ollivier.     Rev.  de  Gyn.     1913.     20:  No.  1. 

75.  Berkley,  C.    Jr.  Obst.  Gyn.  Brit.  Emp.     1913.     3:34. 


TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES     223 

76.  Von  Franque.  Pathologie  unci  Therapie  der  Genital-Tuberc.  des 
Weibs.  In  Wurtzb.  Abh.  a.  d.  Gesgeb.  d.  Prakt.  Med.  19 13. 
No.  45. 

yy.     Minto.     Gin.  Mod.     Dec,   1910. 

78.  Norris,  C.  C.  Gonorrhea  in  Women.  Philadelphia,  191 3. 
Saunders. 


CHAPTER  X 

UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS 

Tuberculosis  and  neoplasms — Ways  of  occurrence — Etiologic  relation  to  cancer — His- 
tologic similarity  of  certain  forms  of  tuberculous  salpingitis  to  carcinoma  of 
fallopian  tube — Types — Cases  recorded — Tuberculosis  and  non-malignant  tumors 
of  the  genital  tract — Accidental  or  coincidental  combinations — Pseudoneoplasms 
— Etiology — Infection  of  adenomyomata  of  uterus — Cases — Ovarian  cysts — His- 
tology— Summary — Tuberculosis  of  uterus  causing  pyometra — Illustration — Tu- 
berculous tubal  lesions — Torsion  of  tuberculous  pyosalpinges — Factors — Action  of 
diaphragm  in  cases — Rupture  of  tuberculous  pyosalpinges — Collected  statistics — 
Rupture  of  pyosalpinx  in  adjacent  hollow  viscera — Necessity  for  thorough  pelvic 
examination — Extension  of  tuberculosis  from  pelvic  lesion  to  other  distinct 
areas — Tuberculous  lesions  in  hernial  sacs — Histologic  study — Cases  cited — 
Bibliography. 

TUBERCULOSIS  AND  NEOPLASMS 

A  combination  of  tuberculosis  and  neoplasms  of  the  genital  tract 
may  occur  in  one  of  two  ways.  A  tuberculosis  may  be  implanted  upon 
a  genital  tract  already  the  seat  of  a  neoplasm  and  involve  the  tumor  either 
on  the  surface,  or,  less  frequently,  in  the  substance  of  the  new  growth. 
The  reverse  may  occur,  that  is,  a  neoplasm  may  develop  from  the  genital 
tract  already  the  seat  of  a  tuberculosis.  The  pathological  process  resulting 
from  either  of  these  combinations  may  be  identical,  as  far  as  the  macro- 
scopic and  microscopic  examination  is  concerned.  In  other  words,  a 
combination  of  a  tuberculosis  and  a  neoplasm  may  be  purely  an  accident, 
the  one  having  no  relation  to  the  etiology  of  the  other.  On  the  other 
hand,  if,  for  example,  it  is  found  that  the  coexistence  of  cancer  of  the 
fallopian  tubes  and  tuberculosis  is  more  frequent  than  would  occur  from 
a  mere  accident  from  these  two  conditions,  another  explanation  must  be 
sought  for.  From  a  study  of  a  large  series  of  cases  and  of  the  literature 
bearing  upon  this  subject,  it  would  appear  that,  as  far  as  cancer  of  the 
fallopian  tubes  is  concerned  a  preexisting  chronic  inflammation,  such  as 
is  produced  by  tuberculosis,  bears  at  least  some  etiologic  relation  to  the 
occurrence  of  cancer;  and  this  is  what  would  be  expected,  if  the  Ribbert 
theory  of  preexisting  irritation,  lessened  resistance  from  preexisting 
inflammation,  etc.,  is  taken  into  consideration.     When,  however,  a  tuber- 

224 


UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS     225 

culosis  of,  let  us  say,  the  endometrium  and  tubes  exists  in  a  patient  in 
combination  with  a  uterine  myoma,  the  accidental  occurrence  of  the  two 
conditions  is  probably  the  explanation.  For,  although  little  is  known 
regarding  the  etiology  of  uterine  myoma,  the  concurrences  of  these  two 
conditions  are  of  no  greater  frequency  than  would  be  expected  from  the 
incidence  of  these  lesions.  Given,  however,  a  tuberculosis  of  the  body 
of  the  uterus  and  a  cervical  carcinoma,  the  occurrence  of  these  two  condi- 
tions is  less  clear,  and  while  still  the  theory  of  accidental  occurrence  of 
a  carcinoma  upon  a  tuberculous  uterus  is  the  most  probable,  the  constant 
irritation  to  the  cervical  mucosa  resulting  from  the  discharge  incident  to 
the  preexisting  endometritis  may  in  some  degree  be  an  etiologic  factor. 

Tuberculosis  and  Carcinoma. — Harris,1  Oertel,2  Wolf,3  Schwalbe,4 
Cone,5  Pepper  and  Edsall,6  and  many  others  have  recorded  the  existence 
of  tuberculosis  and  cancer  in  organs  other  than  the  genital  tract.  The 
researches  of  Levin  7  to  some  extent  bear  out  the  Ribbert  theory  regard- 
ing the  etiology  of  carcinoma.  This  author  showed  experimentally  that 
healthy  testes  of  the  rat  withstood  implantation  of  the  Flexner-Jobling 
tumor,  but  that  when  certain  irritants  were  primarily  applied  a  "take'' 
was  almost  constant.  Kellert  8  states  that  certain  observers  have  con- 
cluded that  tuberculosis  and  its  toxins  are  more  or  less  directly  to  be 
considered  in  the  etiology  of  cancers.  Dixon,  Smith  and  Fox  9  have 
apparently  proved  in  animals  that  under  certain  conditions  the  tubercle 
bacillus  and  its  products  may  stimulate  epithelium  to  abnormal  growth. 

As  regards  the  combination  of  tuberculosis  and  carcinoma  in  the 
genital  tract,  it  seems  safe  to  assume  that  they  may  occur  accidentally 
in  the  same  patient,  or  the  inflammation  may  be,  at  least  to  some  extent, 
a  causative  factor  in  the  production  of  the  cancer ;  the  latter  is  especially 
likely  to  be  the  case  when  the  neoplasm  develops  directly  upon  the  tuber- 
culous process,  as  in  the  case  of  tuberculosis  and  carcinoma  of  the  fal- 
lopian tubes,  and  much  less  probable  when  the  two  occur  at  distant  parts 
of  the  genital  tract. 

An  example  of  both  these  types  occurring  in  one  patient  has  been 
reported  by  Lipschutz.10  The  patient  was  a  multipara,  forty-four  years 
of  age,  in  fairly  good  general  condition.  She  suffered  from  pain  in  the 
back  and  lower  abdomen.  The  uterus  was  irregularly  enlarged,  in  retro- 
position  and  adherent.  A  diagnosis  of  myoma  with  adhesions  was  made. 
Supravaginal  hysteromyomectomy  and  bilateral  salpingo-oophorectomy 
were  performed.  The  uterus  was  as  large  as  a  man's  fist  and  contained 
a  number  of  intramural  myomata.  The  right  fallopian  tube  at  the 
ampulla  passed  into  a  tumor  the  size  of  a  hazel  nut.  Histologic  examina- 
tion of  this  showed  it  to  contain  typical  tubercles,  and  sections  from  the 


226        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

center  of  the  tumor  revealed  the  presence  of  a  papillary  carcinoma.  Lip- 
schutz  believes  that  the  carcinoma  in  this  case  developed  on  an  old 
tuberculous  salpingitis.    There  was  no  recurrence  five  years  afterward. 

Von  Franque  1X  has  also  recorded  the  history  of  a  case  in  which  a 
cancer  developed  on  an  old  tuberculous  lesion.  In  studying  16  cases 
of  the  coincident  occurrence  of  cancer  and  tuberculosis  in  the  genital 
tract  which  he  has  collected  from  the  literature,  this  author  states  that 
in  none  was  there  positive  evidence  that  the  carcinoma  preceded  the 
tuberculosis,  whereas  in  9  the  reverse  was  known  to  be  the  case.  In  only  1 
of  these  specimens  did  the  cancer  actually  develop  in  a  tuberculous  process, 
in  7  the  two  were  closely  adjacent,  and  in  5  they  were  some  distance  apart. 
The  fact  that  carcinoma  is  an  acute  condition  and  that  tuberculosis  is 
essentially  a  chronic  one,  would,  even  apart  from  any  acceptation  of  Rib- 
bert's  theory,  to  a  large  extent  explain  the  preexistence  of  tuberculosis 
in  many  of  these  cases.  Similar  cases  are  recorded  by  L'Esperance,12 
Devic,13  Kaufmann  and  Wallart,14  Lady  Barret,15  Maikoff,16  Glockner,17 
and  others. 

Von  Franque  n  has  recorded  the  history  of  another  case,  in  which 
a  carcinoma  developed  in  a  fallopian  tube,  the  seat  of  an  old  salpingitis. 
In  this  specimen,  however,  the  tumor  originated  from  a  point  in  the 
mucosa  apparently  free  from  the  tuberculous  process. 

D'Halluin  and  Delral 18  have  reported  the  history  of  an  interesting 
case  in  which  the  uterus  and  adnexa  were  fused  into  an  inflammatory 
mass  the  size  of  a  man's  fist.  The  fundus  of  the  uterus  was  the  seat  of 
an  adenocarcinoma  and  was  surrounded  by  a  tuberculous  endometritis. 
The  authors  believe  that  the  cancer  developed  from  tuberculous  granu- 
lations. Nassauer  19  has  reported  the  history  of  two  cases  in  which 
tuberculosis  of  the  endometrium  coexisted  with  carcinoma  of  the  cervix, 
and  Wallart  20  has  described  a  case  of  carcinoma  of  the  cervix  coexistent 
with  a  similar  infection. 

In  the  chapter  on  Pathology  attention  has  been  called  to  the  histologic 
similarity  of  certain  forms  of  tuberculous  salpingitis  to  carcinoma  of 
the  fallopian  tube.  Especial  care  should  be  exercised  in  histologically 
differentiating  these  conditions. 

Tuberculosis  and  Non-Malignant  Tumors  of  the  Genital  Tract. 
— Combinations  of  tuberculosis  and  non-malignant  neoplasms  of 
the  genital  tract  are  by  no  means  infrequent,  and  for  the  most  part  should 
be  viewed  as  accidental  or  coincident  combinations.  In  our  series  of 
cases  of  tuberculosis  of  the  genital  tract  this  infection  has  been  present 
twice  in  conjunction  with  ovarian  neoplasms,  and  once  with  a  uterine 
myoma.    Kelly,21  in  the  examination  of  1,800  uterine  myomata,  observed 


UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS     227 

one  case  in  which  there  was  tuberculous  endometritis,  and  another  in 
which  the  adnexa  were  tuberculous.  The  frequency  of  these  combinations 
is  of  importance  from  a  clinical  viewpoint,  as  in  most  cases  the  predomi- 
nance of  symptoms  and  the  findings  on  palpation  point  to  a  diagnosis  of 
the  tumor,  and  as  a  result  the  tuberculosis  may  be  overlooked,  unless 
care  is  exercised.  A  careful  histologic  examination  is  therefore  indi- 
cated, for,  as  pointed  out  in  a  previous  chapter,  special  postoperative 
treatment  is  indicated  to  all  tuberculous  patients.  In  a  smaller  proportion 
of  cases  the  symptoms  resulting  from  the  tuberculosis  will  be  found  to 
mask  those  produced  by  the  tumor.  Pseudoneoplasms  are  frequent  in 
certain  forms  of  tuberculosis,  as  in  salpingitis  ischmaia  nodosa  or  in 
some  of  the  hypertrophic  forms  of  this  infection,  such  as  are  sometimes 
observed  in  the  cervix,  vagina,  or  external  genitalia.  In  tuberculous 
peritonitis  pseudo  tumors  are  of  frequent  occurrence.  Tuberculosis  of 
the  lower  genital  tract  from  the  internal  os  downwards  frequently  pro- 
duces lesions  which,  upon  clinical  examination  alone,  closely  simulate 
true  neoplasms.  The  ulcerative  lesions  of  the  cervix,  vagina,  and  external 
genitalia  are  especially  likely  to  be  mistaken  for  carcinomata,  and  the 
hypertrophic  forms  may  easily  be  mistaken  for  other  tumors. 

As  has  been  stated,  tumors  of  the  genital  tract  may  be  accidental, 
and  may  develop  either  primarily  or  secondarily  to  the  tuberculosis.  They 
may  spring  from  the  area  attacked  by  the  tuberculosis  or  may  arise 
from  a  distant  and  uninfected  area.  The  tumor  actually  attacked  by 
the  tuberculous  process  may  be  invaded  in  one  of  two  ways,  either  the 
surface  of  the  tumor  may  be  involved,  or  the  actual  substance  of  the 
neoplasms  may  be  infected.  The  former  is  much  the  most  frequent  and 
is  apt  to  occur  when  a  tuberculous  peritonitis  or  even  only  a  salpingitis 
is  present,  in  combination  with  any  intraperitoneal  pelvic  tumor.  The 
ordinary  glandular  ovarian  cyst  seems  especially  subject  to  this  form 
of  tuberculosis.  On  the  other  hand,  and  of  less  frequent  occurrence, 
the  substance  of  the  tumor  may  be  actually  invaded  by  the  tuberculous 
process.  The  etiology  of  this  latter  form  of  infection  probably  occurs 
in  two  ways,  from  without  or  by  a  blood  or  lymphatic  infection  from 
within.  In  the  case  of  ovarian  cystadenomata  the  infection  from  without 
is  the  most  frequent,  either  as  a  direct  extension  from  the  capsule  of 
the  tumor  to  the  underlying  stroma,  or  the  infection  finds  an  avenue  of 
ingress  through  a  ruptured  follicle,  as  more  or  less  normally  rupturing 
graafian  follicles  may  occur  in  these  tumors.  In  the  case  of  infection 
of  an  adenomyoma  of  the  uterus,  especially  of  the  diffuse  variety,  a  direct 
extension  by  continuity  from  a  tuberculous  endometritis  is  probably  the 
avenue  of  contamination  in  the  great  majority  of  cases. 


228        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Ivins 22  reports  the  history  of  a  case  of  an  adenomyoma  of  the 
fallopian  tube  attacked  by  tuberculosis.  In  this  case  the  uterine  end  of 
the  tube  was  the  seat  of  a  firm,  smooth  nodule  the  size  of  a  hazel  nut, 
which  upon  histologic  examination  revealed  the  above  condition.  In  the 
examination  of  tubal  adenomyoma  combined  with  tuberculosis  care  must 
be  exercised,  lest  the  nodules  sometimes  produced  by  a  simple  tuberculous 
salpingitis  be  confused  with  a  true  new  growth.  Miss  Ivins  believes 
her  case  to  have  been  one  of  a  true  tumor  combined  with  a  tuberculosis. 
Von  Franque,11  and  Parsons  and  Glendining  23  have  reported  the  his- 
tories of  cases  in  which  the  specimens  closely  resembled  true  adenomata, 
but  in  which  the  tumor-like  formation  was  probably  the  result  of  tuber- 
culosis, and  not  of  a  new  growth.  Schutze  24  has  described  a  rare  speci- 
men, in  which  the  cervix  was  the  seat  of  an  adenocarcinoma;  a  diffuse 
adenomyoma  of  the  uterus  was  present,  and  distributed  more  or  less  dif- 
fusely throughout  the  latter  tumor  and  especially  involving  its  connective 
tissue  were  many  typical  tubercles.  Many  psammoma-like  bodies  were 
present  in  the  wall  of  the  uterus.  Dickson  25  has  observed  a  specimen  of 
uterine  adenomyoma  invaded  by  tuberculosis.  Multiple  myomata  were 
present  and  all  but  one  of  the  tumors  presented  a  number  of  cheesy 
necrotic  areas,  the  largest  of  these  having  a  diameter  of  5  cm.  Two  small 
subperitoneal  tumors  were  converted  into  white,  necrotic  material  with 
a  consistency  of  putty.  Tuberculosis  of  the  tubes  and  endometrium  was 
also  present.  Kelly  26  remarks  upon  the  extreme  rarity  with  which  tuber- 
culosis is  found  complicating  large  myomatous  uteri.  Heinrich,27  and 
Violet  and  Perrin  28  have  reported  the  histories  of  such  cases.  Grun- 
baum  29  has  described  a  case  of  a  large  uterine  adenomyoma,  in  which  the 
tumor  tissue  was  permeated  with  small  tubercles.  The  myometrium  con- 
tained many  tuberculous  foci  undergoing  cheesy  degeneration.  Tubercu- 
losis of  the  endometrium  and  lungs  was  also  present.  Grunbaum  believes 
the  infection  was  a  hemogenic  one  to  the  endometrium  and  from  thence 
by  direct  extensions  to  the  tumor. 

Archambault  and  Pearce  30  report  the  history  of  a  case  in  which  an 
adenomyoma  of  the  uterus  showed  typical  tubercles.  One  tube  was  the 
seat  of  a  tuberculous  salpingitis,  the  other  tube  and  the  endometrium 
were  normal.  A  pulmonary  tuberculosis  was  also  present.  The  authors 
believe  a  direct  hemogenic  infection  from  the  lungs  occurred,  and  that 
this  case  was  not  therefore  the  result  of  a  spread  from  the  endometrium, 
as  is  usually  the  case  in  these  specimens.  Kelly  and  Cullen  31  have  also 
recorded  a  case  of  an  adenomyoma  of  the  uterus  invaded  by  a  tubercu- 
losis. The  tubes  showed  advanced  tuberculous  salpingitis.  These  authors 
report  another  case  of  tuberculosis  of  the  uterus  associated  with  a  myoma. 


UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS     229 

Grad 32  has  recorded  the  history  of  a  case  in  which  there  was  a 
bilateral  tuberculous  salpingitis  and  an  ovarian  cyst.  The  latter  sprang 
from  the  right  ovary  and  the  tuberculous  tube  was  drawn  out  and  adherent 
over  the  surface  cyst.  Pewsner,33  Logothetopoulos,34  Prussmann,35 
Polloson  and  Violet,36  Meriel,37  and  Poncet  and  Leriche  38  have  described 
cases  in  which  ovarian  cystadenomata  were  invaded  by  tuberculosis. 
Poncet  and  Leriche  go  so  far  as  to  say  that  they  believe  tuberculosis 
to  be  a  definite  etiologic  factor  in  the  production  of  certain  cystic  tumors 
of  benign  type.  They  call  attention  to  the  frequency  with  which  latent 
tuberculosis  is  found  in  patients  who  have  goiter,  and  cite  the  works 
of  several  authors  who  have  shown  by  histologic  examination  that  simple 
goiters  are  often  tuberculous.  They  believe  that  adenomatous  prolifera- 
tion is  one  of  the  ways  in  which  the  thyroid  reacts  to  tuberculosis.  They 
state  that  cysts  of  the  ovary  showing  no  specific  tuberculous  lesions  are 
frequently  found  in  connection  with  tuberculosis  of  the  fallopian  tubes. 
A  number  of  cases  are  cited.  They  conclude  that  these  are  due  to  inflam- 
matory tuberculosis  of  the  ovaries,  which  react  to  the  tuberculous  process 
by  the  formation  of  cysts.  They  do  not  imply  that  all  ovarian  cysts 
are  the  result  of  tuberculosis,  but  think  tuberculosis  is  one  of  the  causes. 

That  tuberculosis  may  produce  cystic  lesions  is  well  recognized,  but 
perioophoritis  is  a  frequent  condition  and  actual  tuberculous  oophoritis 
is  more  frequent  than  formerly  supposed.  Both  these  conditions  may 
lead  to  the  formation  of  retention  cysts,  but  that  cystadenomata  or  other 
forms  of  true  new  growths  are  the  result  of  tuberculosis,  or  even  that 
the  presence  of  tuberculosis  predisposes  to  the  formation  of  ovarian 
neoplasms  is  certainly  far  from  proven.  As  has  been  stated,  a  study  of 
our  material  in  the  laboratory  of  gynecological  pathology  at  the  Uni- 
versity of  Pennsylvania  and  of  the  literature  pertaining  to  this  subject 
does  not  seem  to  the  author  to  bear  out  the  assertion  that  ovarian 
neoplasms  showing  tuberculous  invasion  are  more  frequent  than  can  be 
explained  on  the  grounds  of  the  purely  accidental  combination  of  these 
conditions.  Furthermore,  this  opinion  is  strengthened  by  a  study  of  the 
histology  of  these  tumors. 

To  summarize,  it  may  be  stated  that  the  etiologic  relationship  between 
cancer  and  tuberculosis  is  not  definitely  proven,  but  preexisting  inflam- 
mation is  apparently  at  least  to  some  extent  an  etiologic  factor.  Car- 
cinoma of  the  fallopian  tube  is  in  itself  an  infrequent  tumor,  but  its 
relative  frequency  occurring  with  tuberculosis  is  at  least  suggestive.  The 
assumption  of  Von  Franque  1X  that  the  tumor  rarely  springs  from  the 
area  actively  affected  by  tuberculosis  must  be  taken  with  some  reserva- 
tions.    Tuberculosis  affecting  the  fallopian  tubes  usually  begins  in  the 


230        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

ampulla,  and  this  portion  of  the  tube  usually  presents  the  most  char- 
acteristic histologic  picture  of  the  infection.  "We  believe,  however,  that 
in  most  cases  where  the  disease  is  moderately  advanced,  at  least  all  or 
nearly  all  the  mucosa  of  the  tube  is  involved,  and  the  fact  that,  in  a  given 
specimen,  tubercles  were  not  found  near  the  uterine  end  is  no  proof  that 
this  part  of  the  tube  had  not  been  invaded  to  some  extent.  Filiomyomata 
are  rarely  attacked  by  tuberculosis,  whereas  adenomyomata  are  frequently 
invaded  by  a  direct  extension  from  the  mucosa  and  less  rarely  by  a 
hemogenic  or  lymphatic  infection.  Ovarian  cystadenomata,  when 
occurring  in  conjunction  with  peritoneal  or  pelvic  tuberculosis,  are  fre- 
quently attacked ;  usually  only  the  capsule  of  the  tumor  being  involved, 
less  frequently  and  as  a  result  of  long  standing  or  virulent  infections  or 
occurring  perhaps  as  a  result  of  a  hemogenic  or  lymphogenic  infection, 
the  substance  of  the  tumor  is  invaded.  In  all  cases  care  must  be  observed 
to  differentiate  between  the  pseudoneoplasm,  which  may  be  produced  by 
tuberculosis  alone,  and  true  tumor. 

Tuberculosis  of  the  Uterus  Causing  Pyometra. — It  is  generally 
conceded  that  pyometra  rarely  occurs  except  in  cases  of  malignancy.  In 
a  few  instances,  however,  this  condition  has  been  observed  in  conjunction 
with  tuberculosis,  most  frequently  with  tuberculosis  of  the  cervix, 
although  occasionally  an  extensive  corporeal  endometritis  may  result  in 
shutting  off  of  the  cervical  canal  and  the  consequent  formation  of  a 
pyometra.  Targett 39  presents  an  illustration  of  a  pyometra,  the 
endometrial  cavity  being  much  dilated  and  the  myometrium  markedly 
thinned.  The  endometrium  was  reddened  and  presented  many  small 
punctate  ulcers,  most  of  which  were  superficial.  The  abstracted  reports 
of  a  number  of  cases  of  pyometra,  the  result  of  cervical  tuberculosis, 
are  presented  elsewhere.  Schiffmann  40  reports  the  history  of  an  inter- 
esting case  in  which  a  woman,  who  had  never  menstruated  or  been 
pregnant,  presented  herself  suffering  from  tuberculous  adnexitis.  An 
operation  was  performed  and  the  patient  died  of  a  purulent  peritonitis. 
A  postmortem  showed  that  she  had  suffered  for  years,  probably  since 
childhood,  from  a  tuberculous  metritis,  which  had  resulted  in  occlusion 
of  the  canal  and  which  accounted  for  the  amenorrhea. 

Torsion  of  Tuberculous  Tubal  Lesions. — Tuberculous  pyosal- 
pinges  are  subject  to  the  same  accidents,  as  are  similar  pathologic  proc- 
esses the  result  of  microorganisms  other  than  the  tubercle  bacillus. 
Indeed,  torsion  is  perhaps  more  frequent  in  tuberculosis  than  in  other 
forms  of  pyosalpinges.  Anspach  41  has  especially  emphasized  this  point.' 
The  tendency  of  tuberculosis  of  the  fallopian  tubes  to  produce  large 
retort  shaped  lesions,  often  comparatively  free  from  adhesions,  and  the 


UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS     231 

extreme  chronicity  of  the  disease,  are  all  factors  which  make  torsions 
more  likely  to  occur.  The  fact  that  the  ovaries  are  less  likely  to  be 
severely  attacked  in  tuberculosis  than  in  other  forms  of  pelvic  infection, 
thus  theoretically  lessening  the  extent  of  the  adnexal  adhesions,  may  also 
be  a  factor  in  the  somewhat  more  frequent  occurrence  of  torsion  in  tuber- 
culosis than  in  other  varieties  of  infection  of  the  fallopian  tubes.  For- 
tunately, torsion,  even  in  tuberculous  cases,  is  a  rare  complication. 
Hydrosalpinges  are,  by  reason  of  their  frequent  retort  shape  and  often 
relative  freedom  from  adhesions,  more  prone  to  torsion  than  are  actual 
pus  producing  lesions.  The  exact  etiology  of  torsion  of  inflammatory 
uterine  adnexa  is  difficult  to  determine,  but  is  probably  largely  influenced 
by  the  same  factors  as  are  known  to  produce  so  frequently  similar  acci- 
dents in  cases  of  ovarian  neoplasms.  Among  the  causative  agents,  there- 
fore, are  length  of  pedicle,  irregularity  in  shape  of  the  tumor,  flaccidity 
of  the  abdominal  walls,  alternative  filling  and  emptying  of  the  bladder 
and  rectum,  peristaltic  movements  of  the  intestines,  and  rapid  alterna- 
tions in  the  intra-abdominal  pressure,  such  as  are  produced  by  pregnancy, 
labor,  paracentesis  abdominis,  alternate  distention  and  evacuation  of  the 
intestines,  sudden,  unusual  or  constrained  movements  of  the  body  as  a 
whole,  such  as  stooping,  turning  to  get  out  of  bed,  vomiting,  trauma, 
falls,  jolts,  administrating  of  enemata,  gynecologic  examinations,  and 
pressure  of  the  abdomen  against  a  hard  object,  such  as  a 
wash   tub,    etc. 

Bell 42  lays  particular  stress  upon  the  action  of  the  diaphragm  in 
these  cases.  Payr  43  has  directed  attention  to  another,  and  which  he 
believes  to  be  an  important  factor  in  the  production  of  torsion.  This 
author  believes  that  venous  stasis  in  the  pedicle,  especially  of  small  freely 
movable  tumors,  may  cause  them  to  twist.  The  veins  in  many  such 
pedicles  are  extremely  tortuous,  much  more  so  than  the  arteries,  and,  as 
a  result  of  intense  congestion,  impart  a  spiral  motion  to  the  tumor; 
as  twists  occur  the  stasis  becomes  increased  and  a  sort  of  vicious  circle 
is  formed.  Payr's  article  contains  a  number  of  illustrations.  The  ovarian 
veins  are  normally  unusually  tortuous,  so  that  the  foregoing  theory  is 
particularly  applicable  to  torsion  of  inflammatory  tumors  of  the 
adnexa. 

Symptoms. — Torsion  of  the  inflammatory  tube,  like  torsion  of 
ovarian  neoplasms,  may  be  acute,  the  twist  more  or  less  completely  shut- 
ting off  the  blood  supply  and  resulting  in  gangrene  or  rupture ;  or  it  may 
be  chronic,  causing  a  disturbance  of  the  blood  supply  and  a  mild  exacerba- 
tion of  the  symptoms,  followed  by  a  remission,  and  later  followed  by 
other  twists,  any  of  which  may  be  acute.     Any  degree  of  variation 


2^2        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

between  these  extremes  may  occur,  the  symptoms  usually  depending  upon 
the  degree  of  torsions  and  impairment  of  circulation. 

A  previous  history  of  pelvic  inflammatory  disease  is  usually  present. 
Not  infrequently  a  history  of  some  causative  factor  may  be  obtainable, 
although  sometimes  this  is  absent.  In  63  per  cent  of  the  recorded  cases 
of  torsions  due  to  all  forms  of  infections,  the  patients  have  been  kept 
under  observation  for  a  time  before  operation,  showing  that  in  a  definite 
proportion  the  symptoms  at  the  onset  were  not  very  alarming.  Many 
of  these  cases  were  at  first  mistaken  for  exacerbations  of  a  pelvic  inflam- 
matory disease.  The  seizure  is  almost  invariably  ushered  in  by  an  attack 
of  severe  sharp  pain  over  the  seat  of  the  lesion.  This  is  accompanied  by 
more  or  less  marked  symptoms  of  shock  or  collapse,  followed  shortly 
by  the  evidence  of  acute  pelvic  peritonitis,  which  not  infrequently  becomes 
general ;  nausea,  vomiting,  hyperpyrexia  and  elevation  of  the  pulse  rate, 
with  the  accompanying  evidence  of  peritonitis,  develop.  Vesical  dis- 
turbances, such  as  retention  of  urine  or  irritability  and  frequency  of 
urination,  are  frequently  observed.  Examination  reveals  the  presence  of 
a  more  or  less  tender,  fluctuant  tumor,  which  is  generally  pelvic  in  loca- 
tion. In  cases  in  which  a  pelvic  examination  has  been  made  prior  to  the 
attack,  the  change  in  shape,  size  and  consistency  of  the  tumor  will  be 
of  aid  in  arriving  at  the  correct  diagnosis,  as,  subsequently  to  the  torsion, 
the  tube  becomes  larger,  more  tender  and  more  tense,  and  possesses  a 
somewhat  more  limited  range  of  mobility.  The  enlargement  is  sometimes 
quite  marked.  The  opposite  adnexa  are  usually  found  to  be  the  seat  of 
an  inflammatory  lesion.  A  satisfactory  pelvic  examination  can  rarely 
be  performed  without  an  anesthetic,  owing  to  the  tenderness  and  rigidity 
which  is  generally  present. 

Diagnosis. — The  correct  diagnosis  of  torsion  of  an  inflammatory 
uterine  appendage  is  extremely  difficult  and  rarely  made  (Bell,42 
Anspach41).  For  practical  purposes,  however,  the  character  of  the 
symptoms  and  the  local  findings  are  nearly  always  sufficient  to  call  for 
immediate  operative  intervention  in  the  severe  forms.  The  condition 
is  frequently  mistaken  for  a  torsion  of  a  small  ovarian  cyst  or,  when 
upon  the  right  side,  for  an  acute  appendicitis.  An  important  point  is 
to  determine  between  the  lighting  up  of  a  previously  chronic  inflammatory 
condition  and  a  torsion  or  twisted  hydrosalpinx.  If  a  hydrosalpinx 
undergoing  torsion  is  mistaken  for  an  ovarian  cyst  or  an  acute  ap- 
pendicitis, no  great  harm  is  done,  as  both  require  immediate  surgical 
intervention.  If,  however,  the  condition  is  mistaken  for  an  exacerbation 
of  a  previously  existing  pelvic  inflammatory  disease,  much  valuable  time 
may  be  lost  and  a  general  peritonitis  develop.    The  history  of  Anspach's 


UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS     233 

case  is  as  follows :  Age,  26 ;  symptoms,  simulating  acute  appendicitis. 
Operation  revealed  a  long,  retort  shaped  right  tube  containing  blood  and 
pus,  twisted  two  and  one  half  times  in  the  direction  of  the  hands  of  a 
watch.  Salpingo-oophorectomy  was  performed.  Recovery.  Subsequent 
to  the  operation  the  patient  complained  of  pain  in  the  left  ovarian  region, 
and  a  few  months  later  a  second  operation  showed  a  similar  shaped  fal- 
lopian tube  on  the  left  side.  Microscopic  examination  proved  the  latter 
to  be  tuberculous  in  origin.  The  origin  of  the  infection  in  the  right 
side  was  probably  similar,  but  this  point  could  not  be  positively  deter- 
mined because  of  the  dense  infiltration  with  blood  and  numerous  hemor- 
rhagic infarcts,  which  were  present,  incident  to  the  torsion.  Von 
Meerdervoort  44  has  reported  a  case  occurring  in  a  patient  24  years  of 
age.  Symptoms  of  pelvic  disease  and  pain  in  the  lower  abdomen  had 
been  present  for  5  years.  At  operation  bilateral  suppurative  tubal  lesions 
were  found;  the  right  tube  was  the  seat  of  a  torsion.  Histologically, 
both  pyosalpinges  proved  to  be  tuberculous  in  origin.  Ross 45  has 
reported  the  history  of  a  case  in  which  the  symptoms  appeared  suddenly 
after  cranking  a  motor  car.  The  diagnosis  before  operation  was  acute 
appendicitis,  and  an  emergency  operation  was  performed.  Both  tubes 
were  found  to  have  been  converted  into  tuberculous  pyosalpinges  and 
the  right  was  twisted.  Sampson  46  has  also  recorded  the  history  of  a 
case  occurring  in  a  patient  21  years  of  age.  The  attack  was  sudden  in 
onset  and  simulated  the  symptoms  produced  by  the  torsion  of  an  ovarian 
cyst.  Operation  revealed  bilateral  pyosalpinges,  with  torsion  of  the 
right  tube.  Supravaginal  hysterectomy,  bilateral  salpingectomy,  and 
right  oophorectomy  was  performed.  Histologic  examination  proved  the 
tuberculous  origin  of  the  inflammation. 

Treatment. — Immediate  operative  intervention  is  required  in  all 
cases  of  torsion. 

Rupture  of  Tuberculous  Pyosalpinges. — This  is  a  comparatively 
rare  accident,  but  may  occur  to  any  pyosalpinx.  As  a  result  of  adhesions 
to  surrounding  structures  the  tubal  contents  may  be  discharged  into  the 
intestinal  tract,  bladder,  uterus,  peritoneal  cavity,  or  even  through  the 
abdominal  wall.  Rupture  is  most  likely  to  occur  into  the  rectum  or 
sigmoid  flexure  or  into  the  peritoneal  cavity.  The  latter  is  the  form  of 
rupture  usually  meant  by  most  writers  when  the  term  "rupture  of  a 
pyosalpinx"  is  referred  to.  Ruptures  may  occur  spontaneously  or  may 
be  the  result  of  direct  trauma,  such  as  blows,  kicks,  falls,  rough  pelvic 
examinations,  coitus,  or  labor ;  violent  peristalsis,  straining  at  stool,  may 
also  in  certain  cases  produce  rupture.  It  is  probable  that,  if  pelvic  inflam- 
matory disease  did  not  usually  produce  sterility,  rupture  during  preg- 


234        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

nancy  or  labor  would  be  much  more  frequent.  As  the  growing  uterus 
rises  out  of  the  pelvis  to  which  inflammatory  tubes  are  densely  adherent, 
considerable  traction  is  sure  to  be  caused.  A  drawing  out  and  thinning  of 
the  tube  follows,  which,  if  in  itself  it  does  not  cause  rupture,  produces  a 
lesion  by  the  aid  of  which  a  small  amount  of  trauma  is  sufficient  to 
produce  the  accident.  Indeed,  under  such  conditions  Gonsolin  47  states 
that  tubes,  both  ends  of  which  are  patulous,  may  rupture  as  a  result  of 
traction.  Labor  itself  may  cause  rupture.  Bovee  48  in  19 10  collected 
statistics  from  fifty-five  cases  of  rupture  without  reference  to  the  type 
of  infection,  and  submitted  a  history  of  an  additional  case  from  his  own 
practice.  In  the  majority  of  the  ruptured  cases  there  was  no  assignable 
cause  for  the  rupture.  Undoubtedly  the  acute  exacerbations  of  chronic 
lesions  tend  to  produce  a  condition  favorable  for  rupture,  as  at  these 
periods  more  secretion  is  excreted  into  the  closed  off  tube,  resulting  in 
an  increase  of  intratubal  pressure,  and  the  acute  inflammation  tends  to 
weaken  the  abscess  walls.  Rupture  usually  takes  place  in  the  ampulla 
of  the  tube.  No  rule  can  be  formulated  as  to  the  size  of  a  pyosalpinx 
in  which  rupture  is  most  likely  to  occur.  In  many  of  the  reported  cases 
the  tubes  have  been  small.  Naturally,  those  specimens  in  which  the  walls 
are  thin  and  friable  are  most  prone  to  this  accident.  Adhesions  in  some 
cases  probably  play  an  important  part. 

Symptoms. — These  vary  widely  in  different  cases,  depending  upon 
the  virulence  of  the  organisms  and  the  locality  into  which  the  pus  escapes. 
A  previous  history  of  pelvic  inflammatory  disease  is  generally  obtainable. 
In  twenty-nine  of  thirty-one  cases  of  rupture  into  the  peritoneal  cavity, 
without  regard  to  the  type  of  infection,  collected  by  Bonney,49  in  which 
an  accurate  history  was  obtainable,  the  onset  was  abrupt  and  violent  and 
the  evolution  of  the  symptoms  rapid.  At  the  time  of  accident  a  sharp 
pain  at  the  site  of  the  rupture  generally  occurs,  usually  followed  by 
nausea  and  vomiting.  The  temperature  may  be  normal  or  subnormal  for 
a  few  hours,  and  the  pulse  rapid  and  weak;  pallor,  sweating,  and  other 
symptoms  suggestive  of  an  internal  hemorrhage  are  frequent.  The  tem- 
perature soon  rises  and  other  evidences  of  a  general  peritonitis  become 
manifest.  The  disproportion  between  the  pulse  rate  and  temperature  in 
the  early  stage,  together  with  the  history  of  sharp  pain  perhaps  occurring 
during  straining  at  stool,  trauma,  etc.,  followed  rapidly  by  the  evidences 
of  peritonitis,  are  very  suggestive  of  this  accident. 

Diagnosis. — If  a  pelvic  examination  has  been  made  prior  to  the 
rupture,  examination  subsequently  will  reveal  the  altered  shape  of  the 
tube,  which  is  found  collapsed  and  flaccid,  whereas  previously  it  may 
have  been  easily  defined  as  a  tense  inflammatory  mass.     From  a  practical 


UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS     235 

standpoint,  however,  this  test  is  of  little  value  in  the  average  case,  because, 
even  if  the  surgeon  has  made  a  pelvic  examination  prior  to  the  rupture, 
the  rupture  itself  is  likely  to  produce  so  much  pain  and  tenderness  that, 
on  examination  shortly  after  the  accident,  accurate  outlining  of  inflam- 
matory masses  is  extremely  difficult  or  impossible  without  the  aid  of  an 
anesthetic.  One  of  the  chief  dangers  from  the  rupture,  as  well  as  from 
torsions,  is  that  the  accident  may  be  mistaken  for  a  simple  exacerbation 
of  a  previous  inflammatory  disease  and  therefore  treated  palliatively.  In 
both  these  conditions  it  is  of  the  utmost  importance  that  operative  meas- 
ures be  employed  without  delay.  The  fact  that  the  degree  of  mortality 
bears  a  direct  ratio  to  the  time  elapsing  after  the  accident  and  before  the 
operation  is  amply  proven  by  Bovee,48  Bonney,49  Boldt,50  and  all  others. 
In  these  cases,  the  aim  of  the  surgeon  should  be  to  make  the  diagnosis 
and  operate  before  the  onset  of  the  general  peritonitis,  which  is  almost 
sure  to  follow  a  rupture  into  the  general  peritoneal  cavity.  The  previous 
history  of  the  case,  the  acute  onset,  are  usually  sufficient  to  exclude  the 
ordinary  exacerbation  of  a  pelvic  inflammatory  disease.  When  the  lesion 
is  on  the  right  side,  not  infrequently  these  cases  have  been  mistaken  for 
an  acute  appendicitis.  Torsion  or  rupture  of  an  ovarian  cyst  may  also 
be  readily  confused  with  this  condition.  Fortunately  these  conditions 
require  immediate  operative  intervention,  so  that  a  mistake  in  diagnosis 
under  such  circumstances  is  not  of  vital  importance. 

Treatment. — As  previously  stated,  the  treatment  should  be  imme- 
diate operation.  The  type  of  operation  employed  will  naturally  vary  with 
the  individual  case. 

Rupture  of  a  Pyosalpinx  into  Adjacent  Hollow  Viscera. — Accord- 
ing to  statistics  this  is  probably  a  more  frequent  accident  than  is  generally 
thought,  and  doubtless  its  diagnosis  is  often  overlooked  by  the  keenest 
observers.  The  opening  may  be  direct  into  the  bowel  or  may  be  indirect, 
the  tubal  opening  leading  into  the  bowel  through  a  walled  off  fistular  tract. 
The  former  is  the  more  frequent.  In  a  series  of  tubal  cases  operated  upon 
in  the  University  Hospital  in  the  last  ten  years,  a  number  of  cases  of  this 
kind  have  been  observed,  and,  in  all,  ruptures  had  taken  place  between  the 
tube  and  the  lower  large  bowel.  In  all  the  point  of  rupture  occurred  in  a 
portion  of  the  tube  which  was  adherent  to  the  intestine  and  no  general 
peritoneal  involvement  had  occurred.  Tubal  abscesses  of  tuberculous 
organs  are  perhaps  more  prone  to  this  accident  than  are  like  conditions, 
the  result  of  other  types  of  infection. 

The  rupture  of  a  pyosalpinx  into  the  bladder  is  less  frequent  than 
into  the  bowel,  probably  because,  owing  to  the  anatomic  situation  of 


236        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

the  tube,  vesical  adhesions  are  less  frequent  than  are  similar  lesions  to 
the  bowel.  Violet  and  Chalier  51  believe  that  this  is  not  an  uncommon 
condition.  They  state  that  the  opening  into  the  bladder  may  be  direct 
(tubovesical)  or  indirect  (peritoneovesical),  a  soft,  caseous  mass  inter- 
vening between  the  tube  and  bladder.  The  former  is  the  more  frequent. 
Under  such  circumstances  the  resulting  cystitis  and  the  recovery  of  tu- 
bercle bacilli  from  the  urine  may  lead  to  a  diagnosis  of  renal  infection, 
unless  a  careful  cystoscopy  examination  is  performed.  Kutschner 52 
has  described  a  case  of  this  character,  in  which  a  tuberculous  pyosalpinx 
perforated  into  the  bladder  and  simulated  bilateral  renal  tuberculosis. 
Israel 53  reports  the  history  of  a  similar  case.  The  patient  was  a  young 
woman  suffering  pain,  failing  health,  loss  of  weight,  night  sweats,  fever, 
dysuria  and  pyuria.  On  the  first  urine  analysis  tubercle  bacilli  were 
demonstrated;  in  the  next  two  examinations  no  tubercle  bacilli  were 
found. 

Cystoscopic  examination  revealed  the  presence  of  a  cystitis  and  a 
tuberculous  ulcer  on  the  right  side  of  the  bladder.  Both  ureters  were 
catheterized  and  tubercle  bacilli  were  demonstrated  by  animal  inoculation 
from  each.  A  second  catheterization  was  performed  with  the  same 
results.  The  diagnosis  of  bilateral  renal  tuberculosis  was  made,  and  an 
unfavorable  prognosis  given.  The  patient  was  sent  to  a  sanatorium ;  1 1 
months  later  she  presented  herself  apparently  in  perfect  health,  having 
gained  38  pounds.  .  Cystoscopic  examination  at  this  time  showed  a  cystitis, 
but  the  ulcer  had  disappeared.  Renal  palpation  was  negative.  An  exam- 
ination under  ether  revealed  a  mass  situated  to  one  side  of  the  uterus. 
The  examination  was  followed  by  hyperpyrexia  and  pelvic  pain,  which 
persisted  for  a  day  or  two.  A  few  days  later  another  urethral  catheteriza- 
tion was  performed,  special  care  being  taken  to  avoid  contamination  of 
the  catheters  in  the  bladder.  Normal  urine  was  obtained  from  both  sides. 
The  diagnosis  was  now  clear.  Abdominal  section  showed  a  tuberculous 
pyosalpinx,  the  lumen  of  which  communicated  with  the  interior  of  the 
bladder  by  a  hollow  band  four  or  five  centimeters  long.  Following 
the  operation  the  pyuria  disappeared,  but  tubercle  bacilli  continued 
to  be  present  in  the  vesical  urine  for  six  months.  The  patient  was 
reported  well  two  years  later.  This  case  illustrates  the  necessity  for 
a  thorough  pelvic  examination  in  all  cases,  and  illustrates  also  how 
easily  the  most  experienced  may  be  misled  by  such  findings  as  reported 
above. 

Aurray  54  has  described  three  somewhat  similar  cases.  He  states 
that  tubovesical  fistulas  rarely  heal  spontaneously.  Violet  and  Chalier  51 
report  the  histories  of  three  cases  of  this  kind  and  urge  the  necessity  for 


UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS     237 

operation  in  such  cases,  recommending  that  generally  an  abdominal 
hysterectomy  and  bilateral  salpingo-oophorectomy  be  performed.  The 
portion  of  the  bladder  surrounding  the  fistulous  opening  should  be  ex- 
cised and  the  bladder  closed.  Vaginal  drainage  is  indicated  in  most  cases 
of  rupture.1 

Extension  of  Tuberculosis  from  Pelvic  Lesion  to  Other  or  Dis- 
tant Areas. — In  a  previous  chapter  the  extreme  rarity,  but  occasional 
occurrence,  of  primary  genital  tuberculosis  has  been  pointed  out.  If  it 
is  accepted  that  primary  genital  tuberculosis  exists,  it  therefore  follows 
that  extensions  from  such  a  focus  may  occur.  This,  however,  is  more 
theoretic  than  practical,  because  of  the  rarity  of  primary  genital  lesions. 
Under  certain  circumstances,  such  as  loss  of  continuity  of  the  vaginal 
mucosa,  or  chemical  irritation,  either  local  or  distant  tuberculous  lesions 
may  be  produced  by  the  introduction  into  the 'vagina  of  virulent  tubercle 
bacilli.  It  is  of  importance  to  recognize  that  distant  lesions,  such  as 
pulmonary  tuberculosis,  etc.,  may  in  rare  instances  be  thus  produced.  It 
should,  however,  be  emphasized  that  such  results  only  occur  under  special 
conditions  which  favor  infection,  and  are  by  no  means  the  rule. 

As  has  been  stated  in  the  resume  of  primary  and  secondary  genital 
tuberculosis,  what  frequently  does  occur  is  that  there  is  a  well  marked 
secondary  genital  lesion,  and  the  primary  lesion  in  the  lungs  or  elsewhere 
has  undergone  partial  resolution,  or  is  of  such  small  size  that  its  clinical 
demonstration  is  almost  impossible  with  any  degree  of  certainty.  In 
these  cases  it  seems  probable  that  an  active  pelvic  lesion  may  be  the  focus 
for  an  extension  of  the  infection,  even  to  a  distant  part  of  the  body ; 
and  especially  is  this  true  if  operation  is  performed,  as  the  trauma  may 
open  up  avenues  for  infection  and  break  up  what  formerly  were  walled 
off  collections  of  infectious  material.  Brett 55  has  described  a  case  of 
miliary  tuberculosis  which  he  believes  had  its  origin  from  a  tuberculous 
metritis.  It  seems  likely  that  occasionally  a  spread  of  infection  to  distant 
portions  of  the  body  may  occur  as  a  direct  result  of  an  operation  for 
genital  tuberculosis. 

Tuberculous  Lesions  in  Hernial  Sacs. — The  fact  that  tuberculosis 
of  the  adnexa  usually  produces  adhesions  which  in  themselves  tend  to 
prevent  the  inflammatory  structures  from  entering  hernial  sacs  by  limiting 
the  range  of  mobility  is  one  of  the  chief  reasons  for  the  rarity  with 
which  diseased  tubes  and  ovaries  are  found  in  hernial  sacs.     Cullen,56 

*A  more  extensive  resume  of  the  subject  of  torsion  and  rupture  of  inflammatory 
uterine  adnexa,  without  regard  to  the  type  of  infection,  may  be  found  in  the  author's 
previous  work,  "Gonorrhea  in  Women,"  Phila.  and 'London,  1913,  pp.  319-355.  This 
includes  literature  and  an  abstract  of  cases, 


238        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Gopel,57  Le  Nouene 58  have  recorded  instances  where  inflammatory 
adnexa  were  discovered  in  hernial  sacs.  In  none  of  these  cases  is  the 
type  of  infection  definitely  stated.  Constantini 59  has  described  a  case  of 
tuberculous  infection  actually  invading  an  inguinal  hernia,  in  a  woman 
40  years  of  age.  Morrison  60  has  also  recorded  the  histories  of  a  series 
of  cases  in  which  tuberculosis  occurred  within  hernial  sacs.  He  states 
that  in  the  Royal  Hospital  for  Sick  Children,  Edinburgh,  tuberculosis 
was  present  in  2  per  cent  of  all  herniae.  The  condition  is  much  more 
frequent  in  children  than  in  adults.  In  1906  Cotte,61  in  a  study  of  a 
series  of  such  cases,  found  25  per  cent  occurred  in  children  under  5  years 
of  age.  Either  the  hernia  or  the  tuberculosis  may  be  the  primary  lesion, 
the  former  being  the  most  frequent.  Jennesco  62  believes  that  the  tuber- 
culosis within  the  hernial  sac  generally  precedes  the  abdominal  tuber- 
culosis, and  not  vice  versa,  as  might  be  supposed.  Morrison,60  however, 
believes  the  latter  condition  the  most  frequent,  and  states  that  there  is  no 
postmortem  record  which  shows  abdominal  tuberculosis  absent  when 
present  within  the  hernial  sac.  He  further  points  out  that  abdominal 
tuberculosis  is  sometimes  difficult  to  recognize  and  may,  therefore,  be 
overlooked.  The  occurrence  of  tuberculosis  in  hernial  sacs  may  be 
viewed  as  purely  accidental,  and  is  of  interest  chiefly  on  account  of  its 
rarity. 

The  interior  of  the  sac  may  present  any  of  the  changes  common  to 
tuberculous  peritonitis,  the  variety  in  most  cases  corresponding  with  that 
present  within  the  abdomen.  The  most  frequent  variety  is  that  in  which 
the  peritoneum  is  thickened,  congested,  and  studded  with  grayish 
tubercles.  Perhaps,  as  a  result  of  gravity,  the  fundus  of  the  sac  is  prone 
to  be  the  area  chiefly  attacked,  although  in  some  recorded  specimens  the 
chief  changes  have  been  present  in  the  neck  of  the  sac,  evidently  as  a 
result  of  a  direct  extension  from  within.  The  sac  frequently  contains 
more  or  less  fluid,  the  characteristics  of  which  vary  with  the  type  of  the 
peritonitis  present.  In  some  of  the  recorded  cases  the  peritoneum  of  the 
hernial  sac  has  been  literally  covered  with  tuberculous  granulations,  and 
in  others  the  caseous  or  the  fibrinous  variety  has  been  observed.  In  some 
specimens  the  interior  of  the  sac  has  been  filled  with  an  almost  indistin- 
guishable mass,  macroscopically  resembling  cicatricial  tissue.  Adhesions 
between  the  peritoneum  and  the  other  coverings  of  the  hernia  are  fre- 
quent, and  as  a  result  these  herniae  are  often  irreducible.  Morrison  60 
states  that  in  the  Children's  Hospital  at  Edinburgh  75  per  cent  of  the 
children  coming  for  treatment  suffer  from  some  form  of  hernia.  This 
author  states  that  in  his  series  it  was  impossible  to  demonstrate  abdom- 
inal tuberculosis  by  clinical  methods  in  more  than  36  per  cent  of  cases 


UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS     239 

in  which  the  infection  was  present  in  hernia.  The  end  results  in  Mor- 
rison's series  showed  that  3(11  per  cent)  of  the  27  cases  died  of  tuber- 
culosis, and  3  more  were  seriously  ill  at  the  time  of  writing-.  The  prog- 
nosis is,  therefore,  grave. 

Maylard  63  directs  attention  to  the  fact  that  the  symptoms  of  the 
tuberculosis  are  often  subservient  to  those  of  the  hernia.  He  cites  a  case 
occurring  in  a  child  2  years  of  age,  in  which  the  tuberculosis  was  dis- 
covered accidentally  when  operating  on  the  hernia.  Similar  cases  have 
been  recorded  by  Wallace,64  Kennedy,65  and  Owen.66  In  these  cases  the 
symptoms  of  peritonitis  were  mild  and  the  existence  of  infection  might 
not  have  been  discovered  except  for  the  operations  which  were  performed 
for  the  hernia.  Maylard  63  states  that  the  infection  in  his  case  might 
have  subsided  and  its  presence  never  have  been  known,  but  for  the 
hernia  which  required  operation. 

Tuberculosis  and  Syphilis. — Whether  the  occurrence  of  these  two 
types  of  infection  is  purely  accidental,  or  whether  the  one  in  any  way 
predisposes  towards  the  other,  is  still  somewhat  undetermined.  Pick  and 
Handler67  state,  in  presenting  a  series  of  cases  studied  by  them,  that  31 
per  cent  of  the  deaths  of  these  syphilitic  patients  were  due  to  tuberculosis. 

Tuberculous  Wound  Infection. — This  is  by  no  means  of  rare 
occurrence,  and  is  particularly  likely  to  occur  when  drainage  is  employed 
and  tuberculous  material  left  behind.  An  instance  of  this  type  of  infec- 
tion is  often  observed  in  the  fistulas  following  nephrectomy  for  tuber- 
culosis of  the  kidney.  Occasionally  the  same  thing  occurs  after  operation 
for  tuberculous  peritonitis  or  adnexitis.  A  rare  complication  is  that 
observed  by  Edebohls.68  This  author  operated  upon  a  patient  for  bilateral 
tuberculous  pyosalpinges.  A  miliary  tuberculosis  of  the  peritoneum  was 
present.  The  wound  healed  satisfactorily,  but  subsequently  a  tuberculous 
infection  of  the  cicatrix  developed,  which  required  a  second  operation. 

Tuberculous  Salpingitis  as  an  Etiologic  Factor  in  Tubal  Preg- 
nancy.— The  fact  that  salpingitis  is  a  frequent  etiologic  factor  in  the 
production  of  tubal  gestation  is  well  known.  Fehling 69  reports  the 
results  obtained  in  170  cases  of  early  extra-uterine  pregnancy,  in  nearly 
half  of  which,  when  a  careful  examination  was  possible,  the  opposite 
adnexa  were  found  diseased.  Cones,70  in  an  analysis  of  202  cases  of 
ectopic  pregnancy,  found  that  83  per  cent  were  accompanied  by  inflam- 
matory lesions.  The  author  71  found  59  per  cent  of  a  series  of  64  cases 
to  have  been  preceded  by  inflammation.  Numerous  other  statistics  could 
be  quoted  bearing  out  the  etiologic  relationship  which  exists  between 
preexisting  salpingitis  and  tubal  pregnancy.  As  tuberculosis  constitutes 
a  definite  proportion  of  all  tubal  infections  (about  7  per  cent),  it  is  but 


240        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

natural  to  expect  to  find  it  a  not  infrequent  etiologic  factor  in  the  causa- 
tion of  tubal  pregnancy.  The  facts  that  tuberculosis  of  the  tubes  is 
usually  bilateral,  chronic  in  character,  and  that  in  this  type  of  infection 
the  tubes  tend  to  remain  patent  longer  than  in  the  ordinary  forms  of 
infection,  all  are  points  which  make  the  likelihood  of  tubal  implantation 
of  the  gravid  ovum  likely  in  this  variety  of  infection.  Croom  72  has 
reported  the  history  of  an  advanced  extra-uterine  pregnancy  •complicated 
with  not  only  a  tuberculosis  of  the  tubes,  but  also  of  the  peritoneal 
cavity. 

Appendicitis  and  Tuberculosis. — Silvestri 73  found  manifestations 
of  tuberculosis  in  45.63  per  cent  of  103  persons  with  appendicitis.  Peri- 
appendicitis, as  an  accompaniment  of  tuberculous  salpingitis  or  peritonitis, 
is  frequent  and  has  occurred  in  a  large  percentage  of  our  cases. 


LITERATURE 

1.  Harris,  W.  H.    Jr.  Med.  Res.     1913.    29:471. 

2.  Ortel.    Jr.  Med.  Res.     1912.    25:503. 

3.  Wolf.     Forts,  d.  Med.     1895.     No.  18. 

4.  Schwalbe.    Virch.  Arch.     1897.     149. 

5.  Cone.    Arb.  a.  d.  Path-anat.  Inst.  z.  Tub.     1894.     u.  2. 

6.  Pepper  and  Edsall.     Am.  Jr.  Med.  Sc.     1897.     114. 

7.  Levin,  I.    Jr.  Exper.  Med.     1912.     15:163. 

8.  Kellert,  E.    Jr.  Am.  Med.  A.     1914.     63:1819. 

9.  Dixon,  Smith,  and  Fox.     Penn.  Health  Bui.     191 1.     No.  24. 

10.  Lipschutz,  K.     Monschr.  f.  Gebh.  u.  Gyn.     1914.     39:     No.  33. 

42:41. 

11.  Franque,  O.   Ztschr.   f.   Gebh.  u.  Gyn.      191 1.     No.  27.      1912. 

69:    No.  2. 

12.  L'Esperance,  E.  S.    Proc.  N.  Y.  Path.  Soc.     17:  No.  6,  8. 

13.  Devic.    These  de  Lyon.     1894. 

14.  Kauffmann   und   Wallart.     Ztschr.    f.   Gebh.   u.   Gyn.      1904. 

15.  Barret,  Lady.    Quoted  by  L'Esperance.     No.  12. 

16.  Maikoff,  S.    Medits.  Oboz.     1914.    80:    No.  19. 

17.  Glockner.    Zentrbl.  f.  Gyn.     1904.    p.  702. 

18.  d'Halluin  et  Delval.     Bui.  et  mem.  soc.  anat.  de  Paris.     July, 

1910. 

19.  Nassauer.    Centrbl.  f.  Gyn.     1895.    No.  29. 

20.  Wallart.     Ztsch.  f.  Gebh.  u.  Gyn.  u.  1. 

21.  Kelly,  J.  K.    Brit.  Med.  Jr.     1905.    2:712. 


UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS     241 

22.  Ivins.    Jr.  Obst.  Gyn.  Brit.  Emp.     191 1.     19:266. 

23.  Parsons,  J.,  and  Glendining,  B.     Proc.  Roy.  Soc.  Med.     3  1238. 

24.  Schutze.     Ztschr.  f.  Gebh.  u.  Gyn.     60:    part  3. 

25.  Dickson.    Am.  Jr.  Obst.     1906.     53  799. 

26.  Kelly,  H.  A.    Operative  Gynecology.     1899.    2:381. 

27.  Heinrich.    Monschr.  f.  Gebh.  u.  Gyn.     1908.    27 :    No.  4. 

28.  Violet  et  Perrin.    Soc.  des.  sc.  med.  de  Lyon.    June  8,  1910. 

29.  Grunbaum,  E.    Arch.  f.  Gyn.    81  :383. 

30.  Archambault,  J.  L.,  et  Pearce,  R.  M.    Rev.  de  gyn.  et  de  chir. 

abd.     Jan.  and  Feb.,  1907. 

31.  Kelly,  H.  A.,  and  Cullen,  T.  S.    Myomata  of  the  Uterus.    Phila- 

delphia and  London,  1909.     p.  335. 

32.  Grad,  H.    Am.  Jr.  Obst.     1910.    60:95. 

33.  Pewsner,  C.    These  de  Lyon.     1913. 

34.  LoGOTHETOPOULOS.     Zentrbl.  f.  Gyn.     1908.    p.  377. 

35.  Prussmann.    Arch.  f.  Gyn.     1904. 

36.  Polloson  et  Violet.    La.  gyn.     1914.     18:66. 

37.  Meriel,  M.  E.    Bui.  soc.  d'obst.  et  de  gyn.  de  Paris.     1913.    2:732. 

38.  Poncet,  A.,  et  Leviche,  R.    Lyon  chir.     1913.     11:     No.  1. 

39.  Targett,  J.  H.    Brit.  Med.  Jr.     1903.    2:959. 

40.  Schiffmann.    Arch.  f.  Gyn.     1914.     103 :     No.  1. 

41.  Anspach,  B.  M.    Am.  Jr.  Obst.     1912.    p.  553. 

42.  Bell,  R.  H.    Jr.  Obst.  Gyn.    Brit.  Emp.     1904.    p.  514. 

43.  Payr.    Arch.  f.  Klin.  Chir.     1902.    68:501.    Also  Ztschr.  f.  Chir. 

1906.     85 :392. 

44.  Von  Meerdervoort.    Med.  tijdscr.  v.  verl.  en  gyn.    p.  175.     Ab- 

stracted in  Frommel's  Jhrber.     1905.    p.  209. 

45.  Ross.    Am.  Jr.  Obst.     1906.    54:653. 

46.  Sampson,  J.  A.    Am.  Jr.  Obst.     1912.    p.  271. 

47.  Gonsolin.     These  de  Lyon.     Quoted  by  Lamoreaux.     Arch.  gen. 

de  chir.     Jan.,  19 10. 

48.  Bovee,  J.  W.    Surg.,  Gyn.,  Obst.     19 10.     10:405. 

49.  Bonney,  C.  W.    Surg.,  Gyn.,  Obst.     1909.    9:542. 

50.  Boldt,  H.  J.    Am.  Jr.  Obst.     1889.    22:262. 

51.  Violet  et  Chalier.    Rev.  de  gyn.  et  de  chir.  abd.    Feb.,  1909. 

52.  Kutschner,  H.     Inaug.  Dis.     Berlin,  1913. 

53.  Israel.    Deutsch.  Med.  Woch.     1913.    39:2295. 

54.  Aurray,  M.    Arch.  mens,  d'obst.  et  de  gyn.     1914.     3:195. 

55.  Brette,  M.     Lyon  Med.     1914.     46:     No.  18,  19. 

56.  Cullen,  T.  S.    J.  Hopk.  Hosp.  Bui.     1906.    p.  152. 

57.  Gopel.    Zentibl.  f.  Chir.     1896.    23. 


242        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 


i> 


59 


8.  Le  Nouene.    Gaz.  de  gyn.     1903.     15 :337- 

Constantini.     Bui.  et  mem.  soc.  anat.  de  Paris.     1914.     89:48. 

60.  Morrison,  J.  T.    Clin.  Jr.     1914.    43 '-609. 

61.  Cotte,  G.     Rev.  de  gyn.  et  de  chir.  abd.     1906.     10:981. 

62.  Jennesco.     Rev.  de  chir.     1891.     11:185,455. 

63.  Maylard,  A.  E.     Brit.  Jr.  Tuberc.     1909.     3:45. 

64.  Wallace,  C.     Tr.  Med.  Soc.     London.     1906.     29:401. 

65.  Kennedy,  A.  E.    Lancet.     1900.    2:581. 

66.  Owen,  E.    Lancet.     1902.    2:1106. 

67.  Pick  und  Bandler.     Tr.  7th  int.  cong.  derm.  syph. 

68.  Edebohls,  G.  M.    Am.  Jr.  Obst.     1892.    25 :96. 

69.  Fehling,  H.    Arch.  f.  Gyn.    92. 

70.  Cones,  W.  P.    Bost.  Med.  Surg.  Jr.     191 1.     164:677. 

71.  Norris,  C.  C.     Gonorrhea  in  Women.     Philadelphia  and  London, 

I9L3- 
Croom,  J.  H.    Jr.  Obst.  Gyn.    Brit.  Emp.     1914.    25:    No.  4. 


/*= 


73.     Silvestri,  T.     Rif.  med.     1920.     36:     No.  2. 


CHAPTER  XI 
PREGNANCY  AND  TUBERCULOSIS 

History — Fertility  of  the  tuberculous — Frequency — Physiology  of  pregnancy  bearing 
on  course  of  tuberculosis — Organs  affected — Puerperium  and  its  bearing  upon 
course  of  tuberculosis — Susceptibility  of  pregnant  women — Strain  of  lactation. — 
Condition  of  children  of  tuberculous  mothers — Infant  mortality — Influence  of 
pulmonary  tuberculosis  on  course  of  pregnancy — Influence  of  pregnancy  on  course 
of  pulmonary  tuberculosis — Tubercle  bacilli  in  mother's  milk — Tuberculin  as 
diagnostic  and  curative  agent — Law  regarding  marriage  of  tuberculous  persons — 
Indication  for  induction  of  abortion  prior  to  fifth  month — Results — Consultation 
and  precaution  prior  to  induction  of  abortion — Choice  of  operation — Sterilization — 
Anesthetic — Technic  of  operation  (during  first  two  months) — Convalescence — 
Technic  and  choice  of  operation  for  emptying  uterus  from  second  to  fifth 
month — Pregnancy  after  fifth  month — Delivery  of  tuberculous  patients — Cesarean 
section — Puerperium,  treatment  during,  nursing — Influence  of  pregnancy  upon 
tuberculous  lesions  other  than  the  lungs — Bibliography. 


HISTORIC 

From  the  early  ages  the  subject  of  pregnancy  in  tuberculous  patients 
has  attracted  marked  attention.  Among  the  early  papers  devoted  to  this 
subject  are  especially  noteworthy  the  contributions  of  Horn,1  Succow,2 
Herrieux,3  Robert,4  Grisolle,5  Dechambre,6  Tott,7  Dubreuille,8  Lassegue,9 
Warren,10  Thomas,11  Caresme,12  and  of  Ortega.13  The  latter  is  a  report 
of  132  pregnancies,  of  which  95  went  to  term,  28  were  premature,  and  9 
aborted.  Third  pregnancies  were  rare.  Ortega  believed  pregnancy  ex- 
erted a  deleterious  influence  on  the  course  of  the  tuberculosis.  Other 
interesting  contributions  to  this  subject  exist,  reference  to  many  of  which 
may  be  found  in  the  article  of  Malsbary*14  from  which  much  of  the 
foregoing  information  has  been  obtained. 

In  reviewing  the  early  literature  of  pregnancy  in  the  tuberculous,  it 
is  interesting  to  find  that  pregnancy  was  for  many  years  believed  to  exert 
a  favorable  influence  on  the  course  of  pulmonary  tuberculosis.  This  is 
probably  due  to  the  fact  that  gestation  tends  somewhat  to  increase  the 
weight  of  the  woman.  This  is,  however,  generally  only  temporary,  and 
after  the  fifth  or  sixth  month  rapid  advancement  of  the  disease  is  likely 
to  occur.    As  early  as  1862  Gassner  15  commented  upon  this  finding.    The 

243 


244        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

increase  in  weight  occurs  chiefly  in  the  latter  months  of  pregnancy,  the 
normal  gain  being  from  1600  to  2500  grams  a  month  (from  3  to  5 
pounds).  According  to  De  Lee,16  the  increase  in  weight  is  due  to  in- 
creased assimilation  of  the  fetus  and  the  secundines,  the  storing  up  of 
fat  and  albumin,  the  accumulation  of  water,  especially  in  the  lower  ex- 
tremities, and  increase  in  the  amount  of  blood.  When  pregnancy  occurs 
in  the  tuberculous  woman,  very  frequently,  even  in  those  cases  in  which 
pregnancy  ultimately  exerts  an  unfavorable  influence,  no  deleterious  re- 
sults occur,  or  at  least  become  manifest  during  the  early  months  of 
gestation. 

Fertility  in  the  Tuberculous. — No  practicing  physician  can  have 
failed  to  observe  the  frequency  with  which  pregnancy  occurs  in  the  tuber- 
culous. This  fact  has  led  many  observers  to  conclude  that  persons  af- 
fected with  tuberculosis  are  unusually  fruitful,  and  that,  as  a  result  of 
the  disease,  the  sexual  appetite  is  increased.  Numerous  observations  have 
been  recorded  to  bear  out  this  assertion.  Sexual  intercourse  is  often 
practiced  even  by  those  in  whom  the  disease  is  advanced.  Simmonds  17 
has  reported  a  case  in  which  a  man  had  intercourse  with  his  wife  on  the 
day  on  which  he  died  from  an  advanced  pulmonary  tuberculosis,  and 
numerous  other  somewhat  similar  instances  have  been  recorded.  The 
fact  that,  as  the  result  of  treatment,  many  tuberculous  patients  are  idle 
may  have  some  bearing  on  the  increased  sexual  desire.  Posthumous 
children  are  frequent  among  the  tuberculous.  Be  the  reasons  what  they 
may,  it  appears  to  be  certain  that  tuberculosis,  even  when  moderately 
advanced,  does  not  materially  decrease  the  sexual  appetite  nor  interfere 
with  fertility.  Cornet 18  quotes  a  number  of  cases  in  which  the  sexual 
appetite  was  apparently  increased  in  the  later  stages  of  tuberculosis,  but 
does  not  accept  these  as  proof  of  an  increased  sexual  appetite;  he  believes 
that,  because  of  bizarre  nature,  observers  are  unduly  impressed  by  them. 
He  holds  that,  in  the  majority  of  cases,  as  the  disease  progresses  the  sex- 
ual desire  is  diminished.  However  this  may  be,  the  fact  remains  that 
pregnancy  in  tuberculous  women  is  of  extremely  frequent  occurrence, 
and,  as  stated,  it  seems  to  be  an  assured  fact  that  the  disease  itself  exerts 
little  or  no  influence  on  conception. 

Tuberculosis  itself  is  essentially  a  disease  due  to  faulty  hygiene;  the 
latter  is  the  most  common  among  the  ignorant  and  poor,  a  class  in  whom 
fertility  is  notorious.  Although  the  fertility  among  the  poor  is  probably 
largely  the  result  of  ignorance  regarding  the  methods  of  preventing  con- 
ception, the  fact  remains  that  pregnancy  and  tuberculosis  frequently  co- 
exist. 

Frequency. — In  1913  Bacon  10  stated  that  32,000  tuberculous  women 


PREGNANCY  AND  TUBERCULOSIS  245 

become  pregnant  annually  in  the  United  States,  and  that  between  44,000 
and  48,000  women  of  the  child  bearing  age  die  of  tuberculosis  every  year. 
Probably  25  per  cent  of  the  latter  have  reached  the  puerperal  state,  or, 
in  other  words,  11,000  or  12,000  tuberculous  pregnant  women  die  an- 
nually. This  writer  believes  that  33  per  cent  of  pregnant  tuberculous 
women  die  in  less  than  one  year  following  labor.  He  points  out  that 
these  data  show  only  a  part  of  the  important  bearing  which  pregnancy 
has  upon  tuberculosis.  Besides  an  increased  mortality  among  tuberculous 
pregnant  women,  the  latter  are  a  source  of  infection  to  the  family  and 
an  important  factor  in  the  spread  of  the  disease. 

The  Physiology  of  Pregnancy  as  It  Bears  Upon  the  Course  of 
Tuberculosis. — The  deleterious  influence  of  pregnancy  on  tuberculous 
women  is  well  known,  and  many  theories  have  been  advanced  to  explain 
this  fact.  During  pregnancy  the  woman  carries  a  double  load,  and,  as 
the  gestation  advances,  the  drain  upon  her  strength  becomes  more  and 
more  marked.  Although  pregnancy  is  a  physiologic  process,  and  one 
that  the  healthy  woman  is  well  able  to  bear,  when  it  occurs  in  a  patient 
whose  resisting  powers  are  weakened  by  disease,  the  extra  stress  may  be 
sufficient  to  overbalance  her  resistance,  and,  as  a  result,  the  disease  may 
progress  rapidly  in  a  woman  who  had  heretofore  held  her  own,  or  who 
had  even  been  successfully  combatting  her  infection.  This  is  true  of  all 
diseases,  but  especially  is  it  so  of  tuberculosis.  Many  of  the  physiologic 
changes  that  occur  as  the  result  of  pregnancy,  and  that  are  commonly 
pointed  out  as  the  cause  for  the  injurious  action  of  pregnancy  hardly 
appear  of  sufficient  importance  during  the  early  stages  to  account  for 
the  rapid  progress  of  the  disease  frequently  observed  at  this  period.  The 
author  believes  that  further  study  of  this  subject  is  required  to  explain 
why  so  many  cases  of  early  pregnancy  show  an  exacerbation  of  the  tuber- 
culous condition. 

Some  of  the  physiologic  reasons  commonly  referred  to  as  exerting 
a  deleterious  influence  on  pregnancy,  and  which  are  doubtless  important 
factors  in  the  latter  months  of  gestation,  are  the  following: 

Lungs, — During  the  latter  months  of  pregnancy  a  change  occurs 
in  the  shape  of  the  lungs,  although  their  capacity  is  but  little  altered; 
the  organs  become  shorter  and  broader  as  the  result  of  upward  pressure 
of  the  gravid  uterus ;  the  diaphragm  is  pushed  up,  and  the  lungs  are  some- 
what retracted  to  the  sides,  thereby  exposing  a  larger  part  of  the  heart. 
These  changes  are  more  marked  in  primiparae  than  in  multiparae,  the 
abdominal  walls  in  the  latter  being  lax.  Respiration  becomes  more  of 
the  costal  type,  owing  to  restriction  of  the  movements  of  the  diaphragm. 
The  respiratory  rate  is  increased — from  24  to  26  a  minute — and  more 


246        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

carbon  dioxid  is  excreted-  (Vejas20).  During  the  last  two  weeks  of 
pregnancy,  when  "lightening"  has  occurred,  the  foregoing  phenomena 
are  less  marked.  In  the  late  months  of  pregnancy  the  condition  just  de- 
scribed may  in  all  justice  be  pointed  to  as  an  etiologic  factor  in  causing 
aggravation  of  the  pulmonary  disease.  But  in  the  early  months  of 
gestation  this  is  not  the  case.  During  the  strain  of  labor  more  or  less 
congestion  of  the  lungs  occurs.  It  can  readily  be  understood  how  such 
straining  efforts  may  exert  a  deleterious  effect  upon  pulmonary  lesions. 

Larynx. — The  frequency  with  which  laryngeal  involvement  occurs 
in  the  pregnant  tuberculous  woman  has  been  commented  upon  by  most 
observers.  Malsbary  14  has  suggested  that  some  relationship  may  exist 
between  this  and  the  so-called  "genital  spot."  Bretteuer  has  called  atten- 
tion to  the  relationship  between  the  "genital  spot"  and  dysmenorrhea. 
Hofbauer  21  has  demonstrated  that,  as  a  result  of  pregnancy,  there  is  an 
increased  congestion  of  the  larynx,  affecting  especially  the  false  vocal 
cords,  and  that  there  is  also  a  slight  cellular  infiltration  of  the  tissue  in 
this  location.  Hofbauer  also  states  that,  in  the  normal  pregnant  woman, 
the  mucosa  of  the  larynx  becomes  reddened  and  swollen,  so  that  a  step 
from  the  physiologic  to  the  pathologic  is  not  unlikely. 

Circulatory  System. — Heart. — It  was  formerly  believed  that,  as 
the  result  of  pregnancy,  the  heart  became  hypertrophied.  Stengel  and 
Stanton  22  showed  that  this  was  not  the  case,  and  that  the  increase  in 
dullness  to  the  left  was  not  the  result  of  hypertrophy  of  the  left  ventricle, 
or  of  any  special  increase  in  work,  but  that  it  was  caused  by  the  upward 
and  outward  displacement  of  the  organ.  These  observers  state,  how- 
ever, that  in  labor  there  is  probably  some  dilatation  of  the  right  ven- 
tricle, but  they  believe  that  there  is  no  material  change  in  the  blood  pres- 
sure prior  to  or  following  labor.  De  Lee  16  asserts  that  in  25  per  cent 
of  cases  a  systolic  murmur  is  present  over  the  base  of  the  heart.  Norris  23 
is  of  the  opinion  that  the  displacement  of  the  heart  tends  to  cause  a  kink- 
ing of  the  large  vessels,  thus  adding  to  the  work  demanded  of  that  organ. 
Wiessner  24  believes  that  this  explains  the  occurrence  of  accidental  pul- 
monary murmurs.  Norris  states  that  in  normal  pregnancy  the  blood 
pressure  rarely  exceeds  120  mm.  of  mercury  and,  if  taken  between  pains 
in  the  second  stage  of  labor,  it  varies  between  130  and  150  mm.  After 
delivery  the  normal  values  are  established. 

During  the  uterine  contractions  of  active  labor  the  pains,  as  well  as 
the  intra-abdominal  compression,  cause  a  much  higher  blood  pressure 
than  is  present  in  the  interim  between  the  pains.  Heynemann  25  observed 
a  fall  of  from  60  to  90  mm.,  following  the  birth  of  the  child. 

During  the  early  months  of  pregnancy  many  ill  nourished  women, 


PREGNANCY  AND  TUBERCULOSIS  247 

and  especially  those  in  poor  circumstances,  suffer  from  a  form  of  chloran- 
emia  (De  Lee).  The  condition  is  very  frequent  among  the  poorer 
classes  of  phthisical  patients — "Virchow's  physiologic  leukocytosis." 
Dietrich  26  has  in  the  main  confirmed  these  findings. 

The  blood  changes  during  pregnancy  are  not  marked,  and  probably 
exert  little  influence  on  tuberculosis,  except  in  those  patients  who  are 
anemic  and  whose  natural  resisting  powers  are  diminished  as  a  result. 
As  is  well  known,  the  ductless  glands  exhibit  special  activity  during  preg- 
nancy. 

Digestive  Tract. — More  or  less  vomiting  or  nausea  occurs  in  about 
50  per  cent  of  pregnant  women.  This  is  especially  likely  to  occur  in 
neurotic  subjects,  and  during  the  early  months  of  pregnancy.  When  vio- 
lent straining  occurs,  the  blood  pressure  is  raised  and  unusual  pressure  is 
exerted  upon  the  lung  tissue.  This  condition  must,  therefore,  be  con- 
sidered when  the  cause  for  the  exacerbation  of  pulmonary  lesions  is 
sought.  Brooks  and  Leuckhardt,27  in  their  recent  investigations,  have 
shown  that  although  vomiting  does  not  always  produce  a  marked  increase 
in  the  blood  pressure,  sharp  rises  often  occur.  These  investigators  state 
that  during  the  vomiting  sudden  and  severe  oscillations  of  the  blood 
pressure  are  of  frequent  occurrence,  and  that  these  may  cause  rupture  of 
a  blood  vessel  that  would  not  occur  with  the  same  degree  of  pressure  but 
with  slower  changes.  As  the  result  of  these  studies,  they  also  show  that 
the  danger  to  the  vascular  system  during  vomiting  is  not  minimized, 
but  that  the  responsibility  is  shifted  from  hypertension  to  the  sudden 
variations  in  the  condition  of  the  circulatory  apparatus.  If  the  vomiting 
becomes  so  serious  as  to  interfere  with  nutrition,  its  deleterious  action 
on  the  course  of  the  tuberculosis  is  most  marked.  All  who  have  studied 
pulmonary  tuberculosis  agree  that  the  phthisical  patient  requires  an  abun- 
dance of  nutritious  food.  If  sufficient  food  cannot  be  taken,  or  if  assimi- 
lation is  interfered  with,  a  great  handicap  is  placed  upon  the  tuberculous 
woman. 

Kidneys. — Throughout  pregnancy  there  is  a  tendency  toward  renal 
disturbances,  and  lesions  of  these  organs  are  subject  to  exacerbations. 
This  is  especially  injurious  to  tuberculous  patients. 

Other  Changes  Incident  to  Pregnancy. — Many  other  changes 
occur  as  the  result  of  pregnancy,  but  a  large  part  of  these  cannot  be  held 
responsible  for  the  aggravation  of  the  pulmonary  lesions.  Exactly  why 
pulmonary  tuberculosis  is  so  prone  to  exacerbation  during  pregnancy  is 
difficult  to  explain,  except  upon  the  broad  ground  that  pregnancy  in  itself 
throws  an  added  burden  upon  the  general  system,  and  that  this  may  in 
some  cases  be  enough  to  overthrow  the  balance  of  resistance  on  the  part 


248        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

of  the  patient.  Hofbauer  (quoted  by  Bandelier  and  Roepke28)  believes 
that  the  increased  predisposition  to  tuberculosis  in  the  pregnant  woman 
is  due  to  a  reduction  of  the  lipolytic  quality  of  the  serum  with  advancing 
gestation,  hyperglycemia  and  certain  physiologic  causes,  such  as  hyper- 
emia, increased  lymphatic  flow,  and  peribronchial  infiltration.  Sergent  29 
suggests  that  the  chlorosis,  anemia,  decalcification,  excessive  excretion  of 
phosphorus,  and  adrenal  insufficiency  incident  to  the  gravid  condition, 
are  determining  factors.  Davis  30  states  that  with  the  growth  of  the 
fetus  a  large  part  of  the  iron  is  appropriated  from  the  mother's  blood, 
and  that  this,  together  with  the  drain  on  the  maternal  calcium,  are  factors 
that  tend  to  deplete  the  woman's  strength.  Davis  also  directs  attention 
to  the  changes  that  take  place  in  the  ductless  glands,  and  states  that  even 
in  normal  pregnancies  6  per  cent  of  women  suffer  from  hyperthyroidism. 
"It  is  a  significant  fact,  at  present  not  explained,  that  the  Abderhalden 
test  for  early  pregnancy  gives  a  positive  reaction  in  non-pregnant  patients 
who  have  tuberculosis.  Evidently  the  disturbances  in  the  blood  caused 
by  pregnancy  are  closely  allied  to  those  of  tuberculosis.  It  seems  reason- 
able to  suppose  that  the  combination  of  these  two  conditions  increases 
the  pathologic  condition."  Friedrich's  31  experiments  upon  rabbits  did 
not  show  that  lipoidemia  favored  the  dissemination  of  tuberculosis;  in 
fact,  they  indicated  the  contrary. 

Puerperium. — Fraught  with  more  danger  than  pregnancy  itself  is 
the  puerperium,  and  here  a  definite  basis  for  the  exacerbation  of  the 
tuberculous  condition  which  so  frequently  occurs  at  this  time  can  be 
determined.  The  patient  has  already  suffered  the  strain  of  pregnancy, 
and  has  undergone  whatever  deleterious  effects  this  exerted.  The  strain- 
ing and  increased  blood  pressure  incident  to  labor  are  probably  frequently 
sufficient  to  break  down  minute,  partially  healed  pathologic  processes,  and 
thus  convert  closed  lesions  into  open  ones.  As  a  result,  hitherto  partially 
or  entirely  encapsulated  tubercle  bacilli  are  liberated  in  more  or  less 
large  numbers.  Many  free  organisms  are  thrown  into  the  blood  stream, 
thus  accounting  for  many  of  the  cases  of  miliary  tuberculosis  that  have 
been  reported  as  occurring  at  this  period.  The  actual  physiologic  ex- 
haustion following  a  difficult  labor  is  also  a  contributing  factor  in  many 
cases.  The  congestion  of  the  lungs  incident  to  labor  must  likewise  be 
taken  into  consideration.  The  prolonged  muscular  exertion,  the  physical 
exhaustion  of  labor,  the  possible  loss  of  blood,  or  the  effects  of  a  general 
anesthetic,  if  one  has  been  used,  are  also  factors  that  must  be  taken  into 
account. 

Tuberculosis  of  the  placenta  has  been  described.  It  suffices  here  to 
state  that  tubercle  bacilli  have  been  found  in  the  placentae  of  tuberculous 


PREGNANCY  AND  TUBERCULOSIS  249 

parturients  by  some  observers  in  40  per  cent  of  cases.  In  the  author's 
series,  virulent  tubercle  bacilli  were  positively  demonstrated  in  about  5 
per  cent  of  a  series  of  cases  comprising  patients  in  various  stages  of  the 
disease.  Tubercle  bacilli  are  prone  to  be  present  in  the  placenta  of  women 
suffering  from  an  active  lesion,  and  especially  if  hyperpyrexia  or  pyrexia 
is  present.  The  organisms  are  much  more  likely  to  be  present  at  term 
than  in  the  immature  placenta.  Placentae  containing  tubercle  bacilli  may 
be,  and  frequently  are,  microscopically  normal.  In  cases  in  which  tubercle 
bacilli  are  present  in  the  placenta  it  is  but  reasonable  to  suppose  that 
organisms  are  also  present  in  the  decidua.  If  this  theory  is  accepted,  it 
follows  that  the  contraction?  of  the  uterus  incident  to  labor  must  force  out 
a  definite  number  of  virulent  organisms  into  the  circulatory  blood  strea«m, 
and  that,  thus  liberated,  these  tubercle  bacilli  may  in  turn  set  up  new 
lesions  and  cause  an  exacerbation  or  the  development  of  a  miliary  form 
of  the  disease.  Von  Bardeleben  32  considers  this  so  serious  a  cause  for 
trouble  that  he  recommends  performing  cesarean  section  and  the  excision 
of  the  placental  sites  prior  to  the  onset  of  labor,  for  the  double  purpose 
of  preventing  the  labor  pains,  which  may  squeeze  out  the  organisms,  and 
the  removal  of  the  possibly  infected  placental  site.  For  the  latter  reason 
some  operators  recommend  excision  of  the  placental  site  and  sterilization 
of  the  patient  by  ligation  of  the  fallopian  tubes,  by  partial  or  total  sal- 
pingectomy, or  by  supravaginal  or  panhysterectomy,  this  being  done  for 
the  purpose  of  preventing  subsequent  conception. 

Another  reason  why  exacerbations  are  so  frequent  during  the  puer- 
perium  is  that  lighting  up  of  the  pulmonary  process  has  really  started 
during  the  pregnancy,  but  has  had  time  only  to  advance  to  such  a  stage 
as  to  attract  definite  attention  by  the  time  the  puerperium  has  been 
reached. 

Lactation. — Lactation,  particularly  when  the  woman  is  below  par, 
as  most  of  the  tuberculous  are,  is  also  a  very  definite  added  strain,  and 
may  in  itself  be  sufficient  to  lower  the  woman's  resisting  powers  to  such 
a  point  as  to  exert  an  unfavorable  influence  on  the  course  of  the  disease. 
As  early  as  1887  Hanau  33  pointed  out  the  dangers  of  auto-infection.  He 
asserted  that  the  excessive  straining,  etc.,  induced  expectoration,  which 
was  frequently  drawn  into  hitherto  uninfected  pulmonary  areas,  only  to 
set  up  fresh  lesions  there.  The  dangers  of  aspiration  in  such  cases  are 
undoubtedly  real. 

Susceptibility  of  Pregnant  Women  to  Tuberculosis. — The  author 
believes  that,  as  a  general  rule,  pregnancy,  and  especially  the  puerperium 
exerts  an  unfavorable  influence  upon  the  course  of  tuberculosis.  Whether 
the  normal  pregnant  woman  is  more  susceptible  to  infection  by  the  tubercle 


250        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

bacilli  is  still  an  open  question.  It  is  certain  that  a  definite  proportion  of 
women  apparently  contract  the  disease  during  either  pregnancy  or  the 
puerperium.  This  is  particularly  true  of  the  wives  of  tuberculous  men 
living  amid  unhygienic  surroundings.  Whether  this  is  due  to  an  in- 
creased susceptibility  at  this  period,  or  to  the  added  strain  on  the  general 
system  is  not  known,  but  both  are  probably  contributing  factors.  The 
change  in  the  general  routine  of  life  incident  to  pregnancy,  and  the 
lessened  amount  of  fresh  air  and  lack  of  exercise  indulged  in  by  preg- 
nant women  may  to  some  extent  also  be  causative  factors  in  some  cases. 
Doubtless  many  cases  in  which  the  disease  is  apparently  contracted  dur- 
ing pregnancy  are  in  reality  exacerbations  of  hitherto  mild  and  unsus- 
pected lesions,  and  as  the  disease  progresses,  clinical  symptoms  become 
manifest,  with  the  result  that  the  condition  is  attributed  to  an  infection 
occurring  during  pregnancy.  Fisbberg  34  found  that,  of  286  married 
tuberculous  women,  107  or  37.4  per  cent  first  noticed  their  pulmonary 
symptoms  after  one  or  more  pregnancies  had  occurred.  Jacob  and  Pann- 
witz,35  in  337  tuberculous  women,  found  that  25  per  cent  traced  the 
origin  or  the  exacerbation  of  their  condition  to  pregnancy.  Trembley  36 
states  that  of  240  cases  of  tuberculous  married  women,  151,  or  63  per 
cent,  gave  a  positive  history  of  the  disease  originating  or  becoming  defi- 
nitely recognizable  either  during  pregnancy  or  the  puerperium.  Turban 
(quoted  by  Schauta37)  found  that  29  per  cent  of  tuberculous  women 
who  had  borne  children  attributed  the  onset  of  their  condition  to  preg- 
nancy or  the  puerperium. 

Funk,38  in  a  series  of  200  married  women  suffering  from  pulmonary 
tuberculosis,  found  that  30  per  cent  first  noticed  symptoms  either  during 
or  shortly  following  pregnancy. 

Grisolle  5  observed  that,  in  a  series  of  2^  cases  of  tuberculosis  in 
pregnant  women,  there  were  apparently  many  instances  in  which  the 
disease  developed  during  gestation.  The  average  duration  of  the  pul- 
monary symptoms  in  this  series  was  gl/2  months.  Maragliano  39  found 
that  59  per  cent  of  tuberculous  women  who  had  been  pregnant  first  no- 
ticed severe  symptoms  during  gestation  or  in  the  puerperium.  Of  100 
cases,  Funk38  found  that  in  43  the  first  symptoms  of  the  pulmonary 
lesion  became  manifest  during  pregnancy  or  shortly  afterward.  The 
average  age  of  these  patients  was  35.7  years.  Combining  these  results, 
we  find,  in  a  series  of  963  cases,  42  per  cent  first  noticed  the  pulmonary 
symptoms  during  pregnancy  or  lactation. 

The  important  points  in  the  study  of  this  condition  are  the  prognosis 
and  the  treatment.  Notwithstanding  the  frequency  of  these  cases  and 
the  amount  of  study  that  has  been  devoted  to  them,  comparatively  few 


PREGNANCY  AND  TUBERCULOSIS  251 

valuable  statistics  have  been  formulated — too  few,  in  fact,  to  permit 
the  drawing  of  any  hard  or  fast  rules.  The  reasons  for  this  are  obvious, 
as  so  many  factors  enter  into  each  case — the  virulence  of  the  infection, 
the  stage  of  the  disease,  the  type  of  infection,  the  resistance  of  the  patient, 
her  social  standing,  mode  of  life,  ability  and  intelligence  to  submit  to 
treatment,  and  the  advancement  of  the  pregnancy  are  all  vital  factors,  to 
be  considered  in  each  case.  Additional  difficulties  encountered  in  the 
compiling  of  statistics  are  that,  with  reference  to  the  pulmonary  condi- 
tions, special  diagnostic  skill  is  required,  and  even  when  this  is  had  the 
most  experienced  may  vary  widely,  since  the  personal  equation  enters 
largely  into  these  cases.  For  present  purposes,  only  broad  statements 
will  be  made.  In  studying  this  subject,  we  cannot  escape  the  fact  that 
no  fixed  rule  can  be  formulated  that  will  apply  to  all  cases,  but  that  each 
case  must  be  considered  individually.  All  points  bearing  upon  the  indi- 
vidual case  must  be  carefully  weighed  before  a  prognosis  can  be  made 
or  a  line  of  treatment  can  be  instituted.  In  considering  the  prognosis  and 
treatment,  a  question  that  immediately  arises  in  the  investigator's  mind, 
and  in  the  minds  of  the  prospective  parents,  is  the  probable  condition  of 
the  child.  Although  this  is  only  of  secondary  importance  to  the  health  of 
the  mother,  it  is  a  point  that  must  and  should  be  definitely  considered. 

Condition  of  the  Child  of  Tuberculous  Mothers. — The  subject  of 
placental  and  congenital  tuberculosis  has  been  dealt  with  somewhat  in  de- 
tail in  a  previous  chapter  and  only  a  brief  review  will  be  given  here.  It 
may  be  accepted  that  pregnancy  or  labor  tends  to  produce  a  tuberculous 
bacillemia,  and  that,  although  this  may  be  infrequent,  as  a  result  virulent 
tubercle  bacilli  may  reach  the  placenta.  The  further  the  pregnancy  is 
advanced,  and  the  more  active  are  the  pulmonary  lesions,  the  more  likely 
is  this  to  be  the  case.  Tubercle  bacilli  are  present  in  the  placenta  far  more 
frequently  than  was  formerly  believed.  The  fact  that  virulent  tubercle 
bacilli  are  present  in  the  placenta  is,  however,  no  conclusive  proof  that 
a  congenital  infection  exists.  Although  tubercle  bacilli  are  not  infre- 
quently present  in  the  placenta  of  tuberculous  women,  congenital  tubercu- 
losis is,  nevertheless,  an  extremely  infrequent  disease,  only  4  undoubted 
cases  of  this  condition  being  recorded  in  the  literature.  Investigators 
have  demonstrated  that  congenital  tuberculosis  may  be  produced  in  a 
small  proportion  of  cases  by  animal  experimentation,  but  even  here  the 
conditions  can  hardly  be  compared  with  those  that  occur  in  the  pregnant 
woman,  as  the  amount  of  culture  of  tubercle  bacilli  introduced  into  the 
pregnant  animals  is  far  in  excess  of  what  could  possibly  occur  in  the 
woman.  It  must  be  admitted,  however,  that  congenital  tuberculosis  does 
occur  occasionally  in  man,  the  condition  being  so  rare,  however,  that  for 


252   GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

practical  purposes,  it  need  not  receive  serious  consideration.  In  nearly 
all  children  affected  with  tuberculosis  the  infection  is  a  postnatal  one. 

The  question  as  to  whether  or  not  the  children  of  a  tuberculous  mother 
exhibit  a  greater  or  lesser  susceptibility  to  this  form  of  infection  is  of 
much  greater  importance,  and  is,  unfortunately,  still  an  unsettled  point. 
Many  convincing  arguments  may  be  arranged  on  both  sides.  The  author 
believes  that  such  children  may  show  a  hypersusceptibility  to  infection. 
This,  however,  is  probably  not  marked.  The  number  of  tuberculous  in- 
fants under  one  year  of  age  who  are  the  offspring  of  tuberculous  parents 
would  seem  to  be  a  strong  argument  in  favor  of  this  belief.  Stutz  40 
states  that  the  children  of  tuberculous  mothers  are  constitutional  weak- 
lings. The  high  mortality  among  these  children  is  probably  dependent 
more  upon  the  unhygienic  environment  and  often  motherless  condition 
to  which  these  children  are  exposed,  than  to  any  hereditary  predisposition. 
As  has  been  stated,  it  is  still  a  mooted  point  whether  children  of  a  tubercu- 
lous mother  exhibit  a  hypersusceptibility  to  tuberculosis.  The  fact  that 
the  mortality  among  infants  of  tuberculous  mothers  is  far  greater  than 
that  among  children  of  healthy  progenitors  has  been  substantiated,  and 
should  be  taken  into  consideration  when  the  question  arises  of  perform- 
ing the  so-called  "therapeutic  abortion."  Thus  Sergent  29  states  that  68 
per  cent  of  children  of  tuberculous  mothers  die.  Parry  41  is  of  the  opinion 
that  50  per  cent  of  these  infants  die  during  early  months  of  life. 

Pankow  and  Kupferle42  states  that  54.5  per  cent  of  these  infants  die 
under  one  year  of  age.  Zirkel  (quoted  by  Pankow  and  Kupferle)  places 
the  mortality  at  58  per  cent;  Deibel  43  at  78  per  cent;  Weinberg  (quoted 
by  Pankow  and  Kupferle)  at  78  per  cent.  Fellner,44  in  a  series  of  289 
children,  found  that  24  per  cent  died  at  birth  or  shortly  afterward.  Sil- 
berman's  45  infant  mortality  was  28  per  cent;  Dirner's  46  37.5  per  cent, 
and  Sergent's  29  68  per  cent.  Parry  41  states  that  50  per  cent  of  children 
of  tuberculous  mothers  die  during  early  months  of  life.  In  a  series  of 
cases  of  laryngeal  tuberculosis  Glas  and  Kraus  47  found  that  60  per  cent 
of  infants  died  within  a  short  time  after  birth.  Trembley  48  asserts  that 
the  offspring  of  tuberculous  parents  are  weak  and  display  a  tendency 
toward  tuberculosis.  Jacobi  (quoted  by  Polak  and  Matthews49)  states 
that  70  per  cent  of  infants  succumb  during  the  first  year.  Weinberg  50 
places  the  proportion  at  67.9  per  cent ;  Zirkel 51  at  58  per  cent.  Thus  it 
is  seen  that  the  combined  results  of  14  observers  show  that  there  was  an 
average  infant  mortality  of  58.83  per  cent  among  children  born  of  tuber- 
culous mothers.  Miller  and  Woodruff52  examined  150  children  of 
tuberculous  parents  and  found  51  per  cent  positively  tuberculous.  Floyd 
and  Bowditch  53  found  66  per  cent.     Kunreuther  r'4  also  emphasizes  the 


PREGNANCY  AND  TUBERCULOSIS  253 

unfavorable  prognosis  for  children  of  tuberculous  mothers,  and  records 
one  family  in  which  there  were  6  children,  of  whom  3  had  died  of  tubercu- 
losis and  all  the  others  were  infected.  Bacon  19  estimates  that,  of  the 
10,000  children  under  5  years  of  age  who  die  annually  in  the  United 
States  of  tuberculosis,  7,500,  or  75  per  cent,  are  born  of  tuberculous 
mothers.  Armand-Delille 55  studied  a  series  of  787  children  born  or 
living  in  175  families,  one  or  more  members  of  which  were  tuberculous. 
Of  these  children,  323  were  placed  in  the  country  and  did  well :  396  were 
not  removed  from  their  infectious  surroundings,  and  of  these  238  devel- 
oped tuberculosis.  From  this  can  be  seen  the  postnatal  danger  to  which 
the  child  of  a  tuberculous  mother  is  exposed. 

Doubtless  a  large  proportion  of  the  mortality  of  the  children  is  the 
result  of  death  or  invalidism  of  the  mother,  which  often  leaves  the  child 
without  adequate  care.  Many  of  the  infants  of  tuberculous  mothers  are 
bottle  fed  even  during  the  mother's  life,  and  the  mortality  among  such 
children  is  naturally  high.  Kings  ford  56  reports  the  result  of  his  study  of 
339  post-mortem  records  of  children  who  had  died  of  tuberculosis.  Of 
these,  162  had  died  during  the  first  two  years  of  life,  and  270  during 
the  first  five  years.  These  records  show  how  fatal  tuberculosis  is  in  the 
young. 

Many  authorities  believe  that  the  children  of  a  tuberculous  mother  are 
constitutional  weaklings.  In  this  the  author  concurs  only  to  a  limited 
extent.  The  author  has  seen  large  healthy  children  born  from  mothers 
in  the  last  stages  of  the  disease.  Some  possible  causes  for  the  high  infant 
mortality  other  than  constitutional  weakness  have  already  been  suggested. 
It  is,  however,  probable  that,  if  a  large  series  of  such  infants  was  com- 
pared with  a  series  from  normal  women,  the  former  would  be  found 
smaller  and  weaker  in  the  average,  and  this  would  probably  also  be  the 
case,  if  a  series  of  infants  of  anemic  or  otherwise  weakened  but  non- 
tuberculous  women  were  studied.  In  other  words,  it  does  not  seem  prob- 
able that  tuberculosis  exerts  any  specific  action  on  the  infant  other  than 
would  be  produced  by  any  other  weakening  condition. 

Influence  of  Pulmonary  Tuberculosis  on  the  Course  of  Preg- 
nancy.— The  question  of  sexual  desire  in  the  tuberculous  has  already 
been  discussed.  The  fertility  of  the  tuberculous  is  a  subject  of  great  im- 
portance. The  tuberculous  woman  is  quite  as  likely  to  conceive  as  is  the 
normal  woman.  Indeed,  Shauta  37  believes  that  tuberculous  women  are 
especially  fertile,  and  states  that  he  has  found  it  necessary  in  some  of 
his  cases  to  induce  abortion  two  or  three  times  in  a  year.  On  the  other 
hand,  Pinard  57  is  of  the  opinion  that  pregnancy  is  relatively  uncommon 
among  women  affected  with  an  active  tuberculosis.     Even  in  advanced 


254        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

cases,  in  this  author's  experience,  conception  is  relatively  infrequent.  The 
employment  of  methods  to  prevent  conception,  so  often  adopted,  is  prob- 
ably the  chief  reason  why  pregnancy  does  not  occur  even  more  frequently. 
After  conception  has  taken  place,  the  tuberculosis  has  little  influence  on 
the  course  of  the  pregnancy  per  se.  As  the  result  of  excessive  coughing, 
progressive  anemia,  or  hyperpyrexia,  abortion  or  premature  labor  may 
occasionally  occur,  but  this  is  comparatively  infrequent.  The  tuberculous 
gravida  is  probably  especially  prone  to  develop  such  complications  as 
renal  disturbances  and  gastric  disorders.  Excessive  vomiting  and  renal 
insufficiency  may  in  themselves  bring  about  abortion  or  miscarriage.  As 
has  been  stated,  in  advanced  cases  abortion  or  miscarriage  occasionally 
occurs,  and  this  is  especially  likely  to  take  place  just  before  a  lethal  ter- 
mination of  the  disease  and  in  the  event  of  a  laryngeal  involvement.  Both 
De  Lee  16  and  Williams  58  state  that  the  disease  does  not  predispose  to 
premature  interruption  of  pregnancy,  unless  the  pulmonary  lesion  be  of 
the  florid  or  fulminating  type.  In  such  cases  the  cough  and  hemoptysis, 
fever,  vomiting,  tuberculous  infection  of  the  placenta  or  decidua,  placental 
hemorrhages,  etc.,  may  precipitate  a  premature  labor.  In  Glas  and 
Kraus's  47  series  of  cases,  28  per  cent  of  patients  with  laryngeal  tubercu- 
losis suffered  premature  labor.  Funk,38  in  a  series  of  100  cases  of  preg- 
nancy and  tuberculosis,  compiling  from  the  total  number  of  pregnancies, 
observed  7.4  per  cent  of  miscarriages  or  abortions;  and  in  a  later  series 
the  same  authority  found  that,  among  200  cases,  miscarriage  or  abortion 
occurred  in  18  per  cent  of  cases.  Landouzy's  (quoted  by  Pinard  57)  ex- 
periments tended  to  show  that  animals  inoculated  with  tuberculosis  before 
pregnancy  takes  place  go  to  term,  but  that  when  inoculated  during  preg- 
nancy, they  may  abort,  the  effect  depending  upon  the  virulence  of  the 
microorganisms. 

Influence  of  Pregnancy  Upon  the  Course  of  Pulmonary  Tubercu- 
losis.— Of  even  more  importance  than  the  life  of  the  unborn  child  is 
the  question  of  the  influence  pregnancy  will  have  upon  the  course  of  the 
tuberculosis  in  the  woman.  Before  undertaking  the  systematic  study  of 
this  condition,  and  influenced  only  by  the  literature  and  a  few  personal 
observations,  the  author  was  of  the  opinion  that  too  much  stress  had  been 
laid  upon  the  deleterious  influence  of  pregnancy  upon  tuberculosis,  and 
he  believed  further  that  most  of  the  German  investigators  were  far  too 
pessimistic  in  their  prognosis  regarding  these  cases,  and  that  their  mode 
of  treatment  was  far  too  radical.  Within  the  last  9  years  the  author  has 
examined  all  pregnant  tuberculous  women  coming  to  the  Henry  Phipps 
Institute  for  treatment.  The  physical  and  bacteriologic  examinations 
have  been  performed  by  skilled  internists,  and  careful  histories  of  the 


PREGNANCY  AND  TUBERCULOSIS  255 

pulmonary  condition,  weight,  and  general  health  have  been  kept.  After 
delivery  each  case  was  kept  under  observation  by  a  social  worker,  who 
visited  the  patient  in  her  home.  Following  the  puerperium  an  endeavor 
was  made  to  have  each  patient  return  to  the  Henry  Phipps  Institute  for 
further  treatment.  New  charts  showing  the  pulmonary  condition  were 
then  made.  The  infants  received  the  necessary  treatment,  and  the  mothers 
were  instructed  in  special  clinics  as  to  the  proper  hygiene,  etc.  A  pelvic 
examination  was  also  made  in  each  case.  In  this  way,  in  the  majority 
of  cases,  the  condition  of  the  patient  has  been  under  observation  for  at 
least  one  year.  Ninety  per  cent  of  the  patients  at  the  Phipps  Institute  are 
foreigners,  and  are,  as  a  general  rule,  an  extremely  ignorant  class,  and 
therefore  unsatisfactory  patients. 

Granting  that  these  patients  are,  as  a  rule,  unfavorable  subjects  for 
treatment,  notwithstanding  the  excellent  work  done  by  the  social  service 
department  of  the  Phipps  Institute,  no  observer  can  fail  to  be  impressed 
with  the  unfavorable  influence  often  exerted  by  pregnancy  on  the  course 
of  pulmonary  tuberculosis.  Again,  however,  we  can  only  generalize, 
and  must  once  more  emphasize  the  fact  that  each  case  must  be  studied 
individually.  In  the  author's  series  not  a  few  cases  of  advanced  tubercu- 
losis, which  were  first  seen  in  the  middle  or  later  months  of  pregnancy, 
withstood  well  the  test  of  the  later  months  of  pregnancy,  labor,  and  the 
puerperium,  and  were  at  least  as  well  six  or  nine  months  after  delivery 
as  they  were  at  the  sixth  or  seventh  month.  Such  cases  are,  however,  the 
exception.  The  author  recalls  one  case  of  advanced  bilateral  pulmonary 
tuberculosis  that  had  been  bedridden  at  the  Phipps  Institute  for  three 
months,  and  that  had  suffered  frequent  and  profuse  hemorrhages.  These 
were  especially  frequent  and  copious  during  the  ninth  month.  The  patient 
was  removed  to  the  author's  service  at  the  Maternity  Hospital,  where 
everything  was  held  in  readiness  for  the  performance  of  cesarean  section, 
as  it  seemed  almost  certain  that  the  strain  of  labor  would  induce  an  ex- 
cessive hemoptysis.  This  patient  was  nursed  carefully  and  when  the 
labor  started  spontaneously,  a  modified  form  of  twilight  sleep  was  in- 
duced. No  hemoptysis  occurred ;  the  first  stage  was  normal,  and  as  soon 
as  complete  dilatation  had  occurred,  delivery  was  effected  with  forceps. 
This  patient  improved  and  was  alive  one  year  later,  although  still  suffer- 
ing from  the  pulmonary  disease.  This  case  is  cited  merely  to  show  how 
difficult  it  is  to  foretell  just  what  is  likely  to  occur  in  a  given  case.  The 
frequent  hemoptysis  that  was  present  during  the  last  months  of  preg- 
nancy, often  brought  on  by  a  slight  attack  of  coughing,  made  it  seem 
likely  that,  with  the  onset  of  labor  pains,  a  copious  hemorrhage  would 
take  place,  and  while  the  labor  was  made  as  easy  as  possible  for  the  pa- 


256   GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

tient,  no  hemorrhage  of  any  kind  occurred.  Furthermore,  the  outlook 
for  this  patient,  even  if  she  did  survive  the  hemorrhages,  was  extremely 
unfavorable.  As  a  matter  of  fact,  the  dreaded  puerperium  was  passed 
without  any  exacerbation,  and  improvement  set  in  almost  immediately 
after  delivery.  In  the  series  of  cases  here  under  discussion,  unfortunately, 
only  too  frequently  the  reverse  occurred.  Patients  who  were  apparently 
favorable  subjects  suddenly  developed  symptoms  of  a  marked  exacerba- 
tion of  the  disease;  in  some  cases  this  occurred  during  the  pregnancy,  but 
in  more  it  took  place  during  the  puerperium. 

A  number  of  authorities  argue  that,  since  no  one  can  tell  which  ap- 
parently favorable  cases  will  do  well  and  which  will  do  badly,  the  correct 
treatment  of  all  cases  of  early  pregnancy  is,  therefore,  to  empty  the 
uterus,  and  thus  be  on  the  safe  side.  However,  the  reverse  is  also  true, 
although,  unfortunately,  in  a  much  smaller  percentage  of  cases.  Even 
the  test  of  pregnancy  is  no  certain  criterion,  as  even  the  cases  that  do 
well  during  this  period  may  suffer  severe  exacerbations  during  the  puer- 
perium. 

Furthermore,  apart  from  an  exacerbation  of  the  pulmonary  condition, 
it  seems  but  logical  to  assume  that  obstetric  complications  will  develop 
more  frequently  in  these  patients  than  in  normal  individuals.  In  nearly  all 
tuberculous  patients,  forceps,  version,  or  some  other  form  of  operative 
delivery  is  indicated,  and  this  in  itself  tends  to  increase  the  likelihood  of 
sepsis,  lacerations,  and  other  complications,  and  thus  to  increase  the 
maternal  and  infant  mortality.  The  anemia  and  general  weakened  con- 
dition of  many  of  the  mothers  also  constitute  a  factor  in  increasing  the 
proportion  of  dystocia  and  other  obstetric  complications.  Lebirt 59  found 
that  pregnancy  had  a  bad  influence  on  the  course  of  tuberculosis  in  75 
per  cent  of  cases.  Deibel  43  found  this  to  occur  in  64  per  cent  of  cases; 
von  Rosthorn  60  in  70  per  cent.  Von  Bardeleben  32  found  this  to  be  true 
in  71  per  cent,  and  states  that  47  per  cent  of  these  patients  died  during 
pregnancy,  labor,  or  the  puerperium.  In  all  von  Bardeleben's  mild  cases 
there  was  more  or  less,  sometimes  only  slight,  aggravation  of  symptoms 
during  pregnancy  or  the  puerperium ;  in  most  of  these  cases  the  acute 
symptoms  subsided,  at  least  to  some  extent,  in  from  8  to  12  months.  In 
this  series  16  per  cent  were  presumably  closed  lesions  when  the  pregnancy 
occurred,  12  per  cent  were  severe  or  acute  cases,  and  all  exhibited  an 
aggravation  of  the  disease,  especially  toward  the  close  of  pregnancy. 
Heiman's  collected  statistics  (quoted  by  Schauta37)  showed  that  pul- 
monary lesions  grew  worse  during  pregnancy  in  73.4  per  cent.  Pankow 
and  Kiipferle  42  found  that  94  per  cent  of  their  cases  of  active  pulmonary 
lesions  grew  worse.     Reiche  61  observed  ill  effects  in  JJ  per  cent,  and 


PREGNANCY  AND  TUBERCULOSIS  257 

Freund  (quoted  by  Pankow  and  Kiipferle42)  in  38  per  cent  of  cases. 
Of  Lobenstine's  62  10  cases,  all  grew  worse  and  only  4  survived  labor  for 
3  months.  Fellner  44  and  Schauta  37  found  that  quiescent  or  mild  chronic 
cases  that  had  been  well  for  a  considerable  period  prior  to  pregnancy, 
suffered  a  relapse  in  68  per  cent  of  cases,  Pradell's  (quoted  by 
Schauta  37)  findings  were  even  less  favorable.  In  a  series  of  1035  cases 
he  found  that  95  per  cent  grew  worse.  Kunreuther  54  also  emphasizes 
the  dangers  incident  to  this  condition.  Merletti  63  found  that  50  per  cent 
grew  worse  during  pregnancy ;  von  Rosthorn,60  70  per  cent ;  Kamina,fj4  50 
per  cent.  Schauta  37  states  that  in  tuberculous  guinea  pigs  pregnancy  dis- 
tinctly shortens  the  life  of  the  animal.  Schauta  quotes  the  authorities 
from  German  sanatoria  to  the  effect  that  only  25  per  cent  of  tuberculous 
women  were  able  to  work  4  years  after  childbirth,  and  that  all  these  are 
by  no  means  cured  cases.  Albeck,  of  Norway  (quoted  by  Schauta37), 
found  that  of  16  cases,  all  of  which  were  treated  in  private  sanatoria  and 
were,  therefore,  presumably  receiving  excellent  treatment,  6  died  within 
15  months.  Essen-Moller  (quoted  by  Schauta37)  reports  that  death  or 
aggravation  occurred  in  50  per  cent  of  his  series  of  sanatorium  patients. 
Schauta  states  that  in  at  least  75  per  cent  of  all  cases  the  disease  was 
aggravated  as  the  result  of  the  pregnancy.  Ebeler,65  from  a  study  of 
32  cases,  recommends  the  immediate  emptying  of  the  uterus  uncondition- 
ally in  every  stage  and  in  any  month  of  pregnancy.  Parry  41  reports 
that  in  her  series  of  38  cases,  all  of  which  were  of  the  severe  type,  50 
per  cent  died  within  2  months  after  labor.  Fellner  44  observed  a  general 
maternal  mortality  of  9  per  cent.  Osier  quotes  Dubois  to  the  effect  that 
"If  a  woman  threatened  with  tuberculosis  marries,  she  may  bear  the  first 
accouchement  well,  the  second  with  difficulty,  and  the  third  never."  Alals- 
bary  14  found  the  highest  mortality  among  primiparae.  Bacon  19  esti- 
mates that  33  per  cent  of  tuberculous  women  who  become  pregnant  die 
in  less  than  one  year  following  labor.  Hoffman  &6  found  that  the  greatest 
mortality  among  tuberculous  women  was  between  the  ages  of  15  and  45 
years  (195.5  Per  100,000  population),  whereas  in  men  the  highest  mor- 
tality was  between  45  and  64  years  (254  per  100,000),  indicating  that 
many  tuberculous  women  die  as  the  result  of  pregnancy  and  childbirth. 
Schlimpert 67  asserts  that  the  greatest  number  of  deaths  from  tuberculosis 
during  pregnancy  occur  in  childbed. 

In  reviewing  the  foregoing  statistics,  a  number  of  facts  must  be  taken 
into  consideration.  A  certain  number  of  cases  of  pulmonary  tuberculosis 
will  exhibit  exacerbations,  even  when  not  pregnant,  and  this  proportion 
must  be  deducted  from  the  figures  here  given  when  considering  the  in- 
fluence of  pregnancy  upon  the  course  of  the  disease.     On  the  other  hand, 


258        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

statistics  compiled  from  maternity  hospitals,  from  which  patients  are 
discharged  in  one  or  two  weeks  after  labor,  no  further  trace  being  kept 
of  them,  are  misleading  in  that  no  note  can  thus  be  made  of  the  exacer- 
bations occurring  in  the  late  puerperium  or  during  lactation.  In  this  class 
belong  the  majority  of  statistics  compiled  from  English  and  American 
hospitals.  Only  when  the  cases  are  carefully  followed  for  at  least  six 
months  (some  authorities  assert  for  two  years  or  more)  can  accurate 
figures  be  obtained.  Owing  largely  to  their  registration  laws,  the  oppor- 
tunities for  the  German  to  gather  figures  were  exceptional,  and  their  sta- 
tistics are  therefore  valuable.  In  reviewing  the  literature  on  this  subject, 
it  must  also  be  remembered  that  in  Catholic  countries  the  general  feeling 
against  the  induction  of  abortion  must  be  taken  into  consideration,  and 
doubtless  influences  the  view  of  many  operators. 

Laryngeal  Tuberculosis. — This  variety  of  tuberculosis  has  its  onset 
with  very  great  frequency  during  pregnancy,  and  always  influences  the 
prognosis  unfavorably.  In  the  author's  experience  this  complication  oc- 
curred most  commonly  in  cases  in  which  the  pulmonary  lesions  were 
active.  However,  Bandelier  and  Ropke  28  state  that  laryngeal  tubercu- 
losis frequently  appears  when  the  pulmonary  condition  is  showing  few 
symptoms.  During  pregnancy  laryngeal  tuberculosis  exhibits  a  marked 
tendency  to  extend,  and  this  despite  any  form  of  treatment.  Von  Soko- 
lowski68  states  that  he  has  observed  cases  of  laryngeal  tuberculosis  that 
have  endured  pregnancy  without  developing  any  serious  complication. 
In  the  author's  experience  this,  however,  is  exceptional.  Milligan  69  states 
that  laryngeal  involvement  occurs  in  from  33  to  40  per  cent  of  all  cases 
of  pulmonary  tuberculosis. 

The  clinical  manifestations  are  difficulty  in  talking,  due  to  weakness 
of  the  vocal  cords,  the  voice  becoming  low  and  hoarse;  the  patient  com- 
plains of  a  feeling  of  fullness  or  tickling  in  the  larynx,  and  there  is  a 
frequent  desire  to  clear  the  throat ;  usually  there  is  more  or  less  difficulty 
in  swallowing.  Any  symptom  suggestive  of  this  complication  demands 
immediate  investigation  and  a  laryngoscopic  examination  to  determine 
with  certainty  the  condition  present. 

Milligan  states  that  hyperemia  of  one  vocal  cord  often  precedes  for 
some  time  a  more  definite  involvement.  As  has  been  stated,  when  laryn- 
geal involvement  occurs,  the  prognosis  becomes  extremely  grave. 
Whether  or  not  this  complication  shall  be  regarded  as  an  absolute  indi- 
cation for  the  interruption  of  pregnancy,  will  be  discussed  under  the  head 
of  Treatment.  Local  treatment  of  laryngeal  tuberculosis  is  often  of  little 
avail.  Some  authorities  recommend  an  application  of  25  per  cent  argyrol 
or  of  some  bland  lotion;  gargles,  the  swallowing  or  holding  in  the  mouth 


PREGNANCY  AND  TUBERCULOSIS  259 

of  bits  of  ice,  and  the  application  of  an  ice  bag  externally  may  give  tem- 
porary relief.  Vagni  70  recommends  electrocauterization.  In  extreme 
cases  trachelotomy  may  be  demanded  as  a  life  saving  measure.  Glas  and 
Kraus 47  state  that  where  there  is  ulceration,  with  relative  stenosis, 
trachelotomy  may  materially  improve  the  laryngeal  condition.  Healed 
laryngeal  lesions  are  prone  to  undergo  exacerbations,  if  pregnancy  takes 
place. 

Practically  all  authorities  recognize  the  gravity  of  laryngeal  involve- 
ment in  tuberculosis.  Fellner,44  in  his  series  of  289  cases,  had  a  maternal 
mortality  of  44  per  cent.  Of  231  cases  of  laryngeal  tuberculosis  collected 
from  the  literature  by  Lobenstine,62  200  died  during  pregnancy,  in  labor, 
or  soon  after — a  mortality  of  86  per  cent.  In  this  series  of  cases  spon- 
taneous abortion  and  premature  labor  were  not  infrequent.  Raspini 71 
emphasizes  the  ill  effects  of  laryngeal  involvement.  In  the  combined 
mortality  statistics  from  all  series  of  deaths  from  tuberculosis  and  preg- 
nancy, cases  of  laryngeal  involvement  constitute  a  very  definite  percentage. 
The  death  rate  among  the  infants  of  these  patients  is  about  60  per  cent. 
Imhofer  72  reports  a  mortality  of  from  86  to  90  per  cent  in  those  cases 
in  which  laryngeal  involvement  ocurs;  Kuttner,  90  per  cent;  Stockel, 
Lasogna,74  Pankow  and  Kiipferle,42  Lubliner,75  von  Sokolowski,68  and 
others  give  practically  similar  figures. 

Influence  of  Lactation  on  the  Course  of  Pulmonary  Tuberculosis. 
— It  is  generally  conceded  that  lactation  exerts  an  unfavorable  influence 
on  the  course  of  pulmonary  tuberculosis.  In  practically  all  our  cases  the 
child  has  been  taken  from  the  mother  and  fed  from  the  bottle,  or,  in  a 
few  instances,  with  a  wet  nurse.  Among  the  extremely  ignorant,  bottle 
feeding  is  undoubtedly  attended  by  a  high  infant  mortality.  In  a  few 
instances  in  our  series  breast  feeding  has  seemed  the  lesser  of  two  evils. 
In  those  cases  the  mothers  were  of  a  class  that  would  make  bottle  feeding 
extremely  dangerous,  and  in  all  these  women  the  pulmonary  lesions  were 
mild  and  there  was  little  or  no  expectoration.  In  two  additional  cases  of 
which  we  have  record  the  mothers  began  nursing  their  children  after 
discharge  from  the  Maternity  Hospital,  despite  instructions  and  warnings. 
In  both  these  cases  the  infants  succumbed  in  less  than  one  year,  and  both 
apparently  from  tuberculosis,  although  this  is  not  certain,  since  post- 
mortems were  not  obtainable.  Clinical  signs  of  the  disease  were,  how- 
ever, present  in  both  instances. 

Tubercle  Bacilli  in  the  Maternal  Milk. — The  question  as  to 
whether  the  mother's  milk  is  likely  to  contain  tubercle  bacilli  is  of  at 
least  theoretic  interest.  In  9  examinations  performed  by  the  author  by 
means  of  animal  inoculation,  no  tubercle  bacilli  were  demonstrated.    The 


260        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

milk  used  for  these  experiments  was  obtained  in  each  case  less  than  one 
week  after  labor,  except  in  one  instance,  in  which  a  mother  with  a  closed 
lesion  was  nursing  a  three  months  old  infant.  Two  of  the  remaining 
cases  wrere  in  the  last  stages  of  the  disease,  whereas  the  remainder  were 
moderately  advanced.  Tubercle  bacilli  have,  however,  been  demonstrated 
in  the  mother's  milk  by  Escherich,  Rabinovitsch,  and  Kempner  (all  quoted 
by  Malshary14).  Auche  76  has  published  an  interesting  article  on  this 
subject.  Bandelier  and  Ropke  28  state  that  the  danger  of  transference  of 
tubercle  bacilli  to  the  infant  through  the  mother's  milk  is  a  very  real  one. 
These  authors  believe  that  the  milk  of  a  tuberculous  woman  contains  a 
toxin  that  lowers  the  resisting  powers  of  the  child.  Cornet 18  was  able 
in  rare  instances  to  demonstrate  the  presence  of  tubercle  bacilli  in  the 
milk  of  tuberculous  women.  Recent  investigations  show  that  tubercle 
bacilli  are  found  in  the  milk  more  frequently  than  was  formerly  believed, 
especially  in  the  miliary  variety  of  the  disease,  or  in  those  patients  suf- 
fering from  an  acute  exacerbation.  It  is,  therefore,  undesirable  to  feed 
the  infants  with  mother's  milk,  even  if  this  be  obtained  by  means  of  a 
breast  pump.  The  chief  danger  of  breast  feeding  to  the  child  is,  how- 
ever, due  to  accidental  contamination,  such  as  occurs  from  infected  fingers 
carrying  tubercle  bacilli  to  the  child's  mouth,  either  directly  or  from  in- 
fection of  the  nipples.  Kissing  and  handling  of  the  infant  by  the  mother 
are  a  fertile  source  of  infection,  and  these  accidental  contaminations  are 
probably  much  more  likely  to  occur  than  is  a  direct  transference  of  the 
disease  by  tubercl-bacilli-bearing  milk,  and  probably  constitute  the  chief 
danger  of  nursing. 

Tuberculin  in  Pregnancy. — Kalabin  (quoted  by  Schauta  37)  recom- 
mended tuberculin  in  the  treatment  of  these  cases.  More  recent  investiga- 
tors have  not,  however,  confirmed  the  value  of  this  remedy.  Martin 
(quoted  by  Schauta)  considers  that  a  positive  ophthalmic  reaction  in  the 
tuberculous  pregnant  woman  is  a  favorable  sign,  as  indicating  the  pres- 
ence of  a  sufficient  number  of  antibodies  to  protect  the  patient  against 
extensive  invasion.  Veit,  Kraus  (quoted  by  Bandelier  and  Ropke28), 
and  Kaminer  (quoted  by  Schauta37)  believe,  as  does  also  the  author, 
that  the  test  is  of  no  value  as  a  diagnostic  sign.  The  cutaneous  reaction 
is  also  valueless  as  a  prognostic  aid.  Even  for  diagnostic  purposes  the 
cutaneous  test  during  pregnancy  becomes  less  certain  in  its  results. 

Tuberculin  During  Lactation. — Palmer  77  states  that  he  has  for 
some  time  employed  tuberculin  as  a  diagnostic  agent  in  certain  cases. 
He  has  used  it  guardedly  in  this  way  from  time  to  time,  and  has  wit- 
nessed many  pronounced  reactions,  without  the  slightest  disturbances  in 
the  infant,  although  he  is  convinced  that  in  at  least  three  instances  the 


PREGNANCY  AND  TUBERCULOSIS  261 

breast  fed  infants  were  clinically  tuberculous  at  the  time  the  mothers  were 
given  the  test.  This  observer  reports  one  case  in  which  the  administra- 
tion of  tuberculin  to  the  mother  was  followed  by  a  definite  exacerbation  in 
the  infant,  from  which  it  died  ten  days  later.  He  concludes  that  in  this 
case  it  hardly  seems  possible  that  sufficient  tuberculin  could  have  reached 
the  child  to  cause  the  slightest  disturbance,  and  he  is  inclined  to  attribute 
the  exacerbation  in  the  infant  to  coincidence.  Nevertheless,  he  directs 
that  extreme  caution  should  be  employed  in  giving  tuberculin  to  nursing 
mothers.  Schlosmann  78  has  employed  the  test  in  49  nursing  mothers ;  in 
18,  or  36.8  per  cent  of  these  there  was  more  or  less  reaction,  but  in  none 
was  the  child  affected  in  any  way.  At  best,  the  use  of  tuberculin  is  not 
without  danger. 

Prophylactic  Measures. — Many  authorities  believe  that  tuberculous 
individuals  should  not  marry.  As  a  general  rule,  marriage  is  more  harm- 
ful for  tuberculous  women  than  for  tuberculous  men.  Indeed,  many  men 
appear  to  improve  after  marriage.  The  danger  to  their  wives  and  possible 
progeny  must,  however,  be  taken  into  consideration.  We  believe  that,  as 
a  general  principle,  it  is  correct  to  advise  the  tuberculous  woman  against 
marriage,  but  a  hard  and  fast  rule  to  this  effect  cannot  be  laid  down. 
Certainly  marriage  should  be  advised  against  in  the  presence  of  any 
active  lesion,  no  matter  how  limited  in  extent.  On  the  other  hand,  it 
seems  too  radical  an  attitude  to  forbid  the  woman  with  a  small,  non-active 
closed  lesion,  which  has  been  in  abeyance  for  two  or  three  years,  to  marry. 
Recent  investigations  seem  to  show  that,  at  least  among  the  intelligent, 
marital  infection  of  tuberculosis  is  less  frequent  than  was  formerly  be- 
lieved. 

Should  a  husband  or  a  wife  become  infected,  sanatorium  treatment 
is  advisable,  at  least  for  a  time,  not  only  for  the  good  of  the  patient,  but 
as  a  means  of  protecting  the  family  and  in  order  that  the  patient  may 
learn  prophylaxis,  to  guard  others.  Some  authorities  recommend  sterili- 
zation of  the  tuberculous  wife,  if  it  becomes  necessary  to  empty  the  uterus 
on  account  of  the  disease.  This  the  author  believes  to  be  unjustifiable, 
except  in  exceptional  circumstances.  Knopf  79  is  of  the  opinion  that  every 
man  who  has  an  active  pulmonary  tuberculosis  should  undergo  a  vasec- 
tomy, and  that  a  bilateral  salpingectomy  should  be  performed  upon  every 
affected  woman. 

Law  Regarding  the  Marriage  of  Tuberculous  Persons. — That 
the  healthy  individual  who  marries  a  tuberculous  person  runs  some  risk 
of  contracting  the  disease  is  well  known,  the  risk  varying  in  degree  with 
the  type  of  the  lesion  and  the  intelligence  of  the  contracting  parties.  The 
Supreme  Court  of  New  York  (Special  Term,  New  York  County,  Sobol 


262        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

vs.  Sobol,  N.  Y.  Supp.  248;  Reference  from  /.  Am.  Med.  A.  1915,64 
1024)  holds  that  fraudulent  concealment  of  tuberculosis  by  a  person  en- 
tering into  the  marriage  relation  is  ground  for  annulment  of  the  mar- 
riage. In  this  case  it  was  established  that  the  defendant  had  been  treated 
for  tuberculosis  prior  to  the  time  of  his  marriage,  and  that  he  knew  that 
he  was  suffering  from  the  disease.  Before  marriage  he  explained  to  the 
plaintiff  that  his  symptoms  were  manifestations  of  a  cold.  Furthermore, 
it  appeared  that,  a  few  days  subsequent  to  the  marriage,  the  defendant's 
condition  was  such  as  to  require  the  services  of  a  physician,  who  diagnosed 
the  case  as  tuberculosis.  The  court  based  its  opinion  on  the  concealment 
of  the  disease,  the  possible  effect  on  one  of  the  contracting  parties,  and 
upon  their  posterity.  The  court  deemed  it  proper,  in  view  of  the  wide 
spread  prevalence  of  tuberculosis  and  the  disastrous  consequences  to  those 
who  suffer  from  it,  to  take  judicial  notice  of  its  characteristics,  for  the 
purpose  of  this  discussion.  There  can  be  no  doubt  that  the  disease  is  of 
an  infectious  nature,  and  that  close  association  with  a  person  thus  af- 
flicted, unless  attended  with  great  care,  exposes  those  coming  in  contact 
with  such  persons  to  the  danger  of  infection.  Tissier  80  states  that  the 
induction  of  abortion  is  against  the  law  in  France,  and  that  it  can  be 
performed  only  by  "the  intelligent  tolerance  of  the  civic  authorities." 

The  chief  danger  to  the  tuberculous  married  woman  is  pregnancy,  and 
her  safest  plan,  regardless  of  the  nature  of  her  lesion,  is  to  avoid  con- 
ception. Although  this  may  be  a  great  hardship  to  her  and  her  husband, 
there  can  be  no  doubt  regarding  the  truth  of  this  assertion.  We  have 
previously  endeavored  to  emphasize  the  necessity  for  individualizing  in 
the  case  of  these  patients.  Occasionally  a  case  may  occur  in  which  the 
lesion  is  limited  in  extent  and  has  been  inactive  for  not  less  than  two 
years.  Under  such  circumstances,  if  the  patient  is  intelligent  and  able  to 
avail  herself  of  proper  treatment  and  supervision,  and  if  she  is  especially 
desirous  of  having  a  child,  conception  is  justifiable.  These  cases  are,  how- 
ever, exceptional,  and  even  under  the  most  favorable  circumstances  such 
a  patient  materially  increases  the  risk  of  bringing  on  an  exacerbation  of 
her  disease.  If  one  or  two  children  are  living  at  the  time  that  the  woman 
becomes  infected  or  seeks  advice,  conception  is  best  advised  against  in 
all  cases.  It  is  impossible  to  escape  the  fact  that  any  form  of  pulmonary 
tuberculosis,  no  matter  how  limited  in  extent,  is  especially  prone  to 
become  aggravated  during  the  pregnancy  and  the  puerperium.  Some 
cases  may  do  well,  and,  as  the  result  of  a  limited  experience,  the  physician 
may  easily  be  led  to  underestimate  the  dangers  of  pregnancy.  Unfortu- 
nately, despite  the  most  painstaking  study,  we  are  as  yet  unable  to  deter- 
mine with  certainty  which  case  will  bear  pregnancy  and  the  puerperium 


PREGNANCY  AND  TUBERCULOSIS  263 

well,  and  which  will  fare  badly.  No  positive  prognosis  can,  therefore,  be 
given  in  the  case  of  an  individual  patient.  At  times,  even  those  cases  that 
appear  most  favorable  will  result  disastrously,  and  occasionally,  though 
unfortunately  only  in  a  small  proportion  of  instances,  the  reverse  will  be 
the  case.  The  safest  plan  for  the  woman,  therefore,  is  to  avoid  concep- 
tion. In  those  exceptional  cases  in  which  conception  has  been  counte- 
nanced, strict  hygienic  measures  must  be  enforced,  and  the  woman  kept 
under  close  observation  and  examined  at  frequent  intervals  by  an  experi- 
enced internist. 

Dice  81  divides  the  non-active  cases  into  two  classes — first,  the  early 
cases,  in  which  the  patients  are  apparently  cured,  where  the  tuberculous 
process  is  arrested,  and  secondly,  those  in  which  the  disease  is  fairly  well 
advanced,  but  has  been  inactive  for  two  or  more  years.  Even  in  the  most 
favorable  cases,  Dice  advises  against  pregnancy,  unless  there  has  been  a 
period  of  quiescence  of  not  less  than  two  years,  and  even  in  such  cases 
he  believes  the  dangers  of  pregnancy  are  by  no  means  small.  In  deter- 
mining the  extent  of  the  pulmonary  lesions  in  non-active  cases,  the  X-ray 
has  been  found  a  valuable  aid. 

Treatment  of  Pregnancy  and  Tuberculosis. — As  a  matter  of  fact, 
the  physician  is  frequently  not  consulted  regarding  the  advisability  of 
either  marriage  or  conception,  and  often  sees  the  case  for  the  first  time 
after  pregnancy  has  taken  place.  This  is  especially  true  of  the  ignorant 
classes,  and  even  the  intelligent  are  as  yet  not  sufficiently  educated  upon 
this  point.  If  pregnancy  has  taken  place,  the  most  important  point  to  be 
decided  is,  shall  the  uterus  be  emptied,  and  if  so,  what  are  the  indications 
for  performing  abortion. 

A  General  Hygienic  and  Dietary  Treatment. — All  cases  of  preg- 
nancy occurring  in  tuberculous  women  should  be  subject  to  a  rigid 
hygienic  and  dietary  treatment.  This  should  be  instituted  as  soon  as 
tuberculosis  is  diagnosed,  but  it  is  especially  important  if  pregnancy 
occurs.  The  pregnant  tuberculous  woman  needs  every  possible  aid  in 
combating  her  infection.  She  should,  therefore,  be  placed  under  the  care 
of  a  physician  who  understands  this  special  form  of  treatment.  If  it  be- 
comes necessary  to  interrupt  the  pregnancy,  there  should  be  as  little  break 
in  the  hygienic  regime  as  possible.  If  the  weather  is  at  all  suitable,  the 
patient's  convalescence  will  be  more  satisfactorily  accomplished  by  placing 
her  out  of  doors.  This  is  particularly  true  of  those  cases  that  have  been 
accustomed  to  an  out  of  door  life  prior  to  the  operation.  Even  in  the 
most  favorable  postoperative  cases,  the  hygienic  regime  should  be  con- 
tinued for  at  least  three,  and  preferably  for  six  or  more  months,  following 
the  termination  of  pregnancy. 


264        GYNECOLOGICAL  AXD  OBSTETRICAL  TUBERCULOSIS 

These  cases  are,  as  a  rule,  best  treated  in  a  well  conducted  sanatorium, 
and  if  the  operation  cannot  he  performed  there,  the  patient  should  be 
removed  to  such  an  institution  as  soon  as  possible  after  the  opera- 
tion. 

EUagxosis. — Presuming  that  the  diagnosis  of  tuberculosis  has  been 
established  beyond  doubt,  the  question  of  the  attitude  the  physician  shall 
assume  is  of  the  greatest  importance.  In  cases  of  early  pregnancy  the 
diagnosis  of  the  latter  condition  is  somewhat  difficult.  Too  much  atten- 
tion must  not  be  paid  to  amenorrhea  as  a  diagnostic  sign,  as  this  is  not 
an  infrequent  symptom  in  tuberculosis.  In  our  series  of  214  cases  of 
tuberculosis  in  which  the  menstrual  changes  were  especially  studied,  total 
amenorrhea  was  present  in  5  per  cent  of  cases,  and  scanty  or  irregular 
flow  was  observed  in  an  additional  53  per  cent  of  patients.  Schauta  37 
states  that  the  opinion  of  the  medical  world  regarding  the  treatment  of 
pregnancy  in  the  tuberculous  may  be  divided  into  three  groups :  the  first, 
the  French  school,  which  admits  the  unfavorable  effect  of  pregnancy  on 
the  course  of  pulmonary  tuberculosis,  but  declines  to  induce  abortion, 
placing  its  hopes  for  success  upon  diet,  hygiene,  etc. ;  the  second  group, 
which  consists  of  those  who  individualize,  and  who  induce  abortion  if 
the  tuberculosis  is  advancing,  but  if  it  is  not,  employ  general  treatment 
and  supervision ;  and  the  third,  which  considers  tuberculosis  an  uncondi- 
tional indication  for  abortion. 

The  author  is  not  in  accord  with  any  of  these  groups,  but  believes 
that  the  attitude  toward  any  given  case  must  depend  upon  the  conditions 
surrounding  it.  In  considering  the  subject,  many  factors  must  be  taken 
into  consideration,  among  the  most  important  of  which  are  the  advance- 
ment of  the  pregnancy  and  the  character  of  the  pulmonary  lesion,  the 
social  status  of  the  patient,  her  intelligence,  whether  she  is  able  and 
willing  to  observe  proper  hygienic  and  dietary  precautions,  her  financial 
condition,  her  mental  attitude,  the  question  of  whether  she  already  has 
one  or  more  children.  These  considerations  are  all  factors  of  the  utmost 
importance,  and  should  be  weighed  carefully  before  determining  upon  the 
treatment  to  be  instituted.  No  hard  and  fast  rules  that  will  be  applicable 
to  all  cases  can,  therefore,  be  laid  down. 

In  the  early  months  of  pregnancy,  with  a  rapidly  advancing  pulmonary 
lesion,  there  can  be  no  question  that  the  induction  of  abortion  should  be 
performed  without  loss  of  time,  and  this  is  also  true  if  laryngeal  involve- 
ment occurs.  On  the  other  hand,  given  a  similar  case  in  the  late  months 
of  pregnancy,  little  can  be  gained  by  the  induction  of  premature  labor. 
The  most  dangerous  period — the  puerperium — will  occur  in  any  event, 
and  under  such  circumstances  it  is  usually  better  to  direct  all  one's  efforts 


PREGNANCY  AND  TUBERCULOSIS  265 

toward  establishing  the  well  being  of  the  child,  as  in  any  event  the  mother 
is  probably  doomed. 

Speaking  on  the  broadest  general  lines,  the  cases  of  pregnancy  in  the 
tuberculous  may  be  divided  into  two  groups,  according  to  the  advance- 
ment of  the  gestation,  the  first  group  consisting  of  those  cases  seen  prior 
to  the  fifth  month,  and  the  second,  those  encountered  from  the  fi'fth 
month  on. 

Indications  for  the  Induction  of  An  Abortion  in  the  Tuberculous 
Prior  to  the  Fifth  Month. — The  writer  believes  that  in  the  presence  of 
an  extensive  lesion,  even  in  the  quiescent  stage,  or  even  of  a  small  active 
lesion,  the  uterus  should  be  emptied  at  once.  This  also  applies  to  those 
cases  in  which  laryngeal  involvement  of  any  degree  is  present.  The  de- 
velopment of  secondary  tuberculous  lesions  in  parts  of  the  body  other 
than  the  lungs  is  also  an  indication  for  this  procedure  in  most  cases. 
Excessive  vomiting,  renal  insufficiency,  and  other  complications  of  preg- 
nancy may,  as  in  the  normal  woman,  constitute  indications  for  emptying 
the  uterus.  It  must  be  remembered  that  the  tuberculous  woman  has  less 
resisting  power  than  the  uninfected  one.  Our  object  is  to  maintain  her 
powers  of  resistance  at  their  highest  point — in  other  words,  to  improve 
her  general  health.  This  is  of  the  utmost  importance.  Gastric  dis- 
turbances or  other  complications  that  might  be  borne  by  the  normal 
woman  may  be  sufficient  to  lower  the  tuberculous  patient's  resisting  pow- 
ers to  such  an  extent  that  an  exacerbation  may  occur.  For  this  reason, 
intervention  should  be  employed  considerably  earlier  in  the  tuberculous 
woman  and  for  a  milder  degree  of  complications  than  in  the  normal 
woman.  Loss  of  weight  is  not  in  itself  an  indication  for  the  induction 
of  abortion.  It  is,  however,  a  danger  signal  of  great  practical  value. 
Veit 82  rightly  lays  special  stress  upon  the  prognostic  value  of  a  loss 
or  a  gain  in  weight.  Women  who  lose  weight  in  the  latter  months 
of  pregnancy  often  succumb  during  the  puerperium.  As  a  general  rule, 
the  earlier  the  intervention,  the  better  is  the  prognosis. 

A  much  more  difficult  point  to  determine  is  the  attitude  of  the  physi- 
cian toward  the  patient  with  a  quiescent  lesion  of  moderate  or  small 
extent.  Here  the  patient  must  be  studied  individually,  and  the  points 
previously  referred  to  considered.  It  must  be  remembered  that  in  every 
such  case  the  woman  runs  an  added  risk  by  allowing  the  pregnancy  to 
continue.  It  is  conceded  that  intervention  in  the  early  months  of  preg- 
nancy is  productive  of  at  least  moderately  good  results,  but  that  interven- 
tion in  the  latter  months  of  gestation  is  of  little  value.  One  of  the  chief 
dangers,  therefore,  in  these  cases  is  that  the  patient  may  do  well  until 
about  the  sixth  or  the  eighth  month,  when  it  is  too  late  to  do  any  good 


266        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

by  emptying  the  uterus.  As  has  previously  been  stated,  it  is  impossible 
to  determine  with  certainty  which  case  will,  and  which  will  not,  do  well. 
On  the  other  hand,  it  is  by  no  means  justifiable  to  advise  the  induction 
of  abortion  in  every  case.  As  a  general  rule,  the  longer  the  lesion  has 
been  inactive,  the  better  is  the  prognosis.  Lesions  of  limited  extent  and 
those  that  have  never  shown  very  marked  activity  are  also  more  favor- 
able. A  factor  of  the  utmost  importance  is  whether  or  not  the  patient 
is  in  a  position  to  obtain  proper  hygienic  and  dietary  treatment.  If, 
during  the  course  of  observation,  and  prior  to  the  fifth  month,  evidence 
of  laryngeal  involvement  or  an  exacerbation  of  .any  sort  arises,  the  safest 
plan  is  to  advise  immediate  intervention. 

Results  of  Abortion  in  the  Tuberculous  Prior  to  the  Fifth  Month. 
— Owing  to  the  many  factors  that  enter  into  their  compilation,  statistics 
are  sometimes  misleading.  The  types  of  cases  from  which  they  are 
drawn,  and  the  closeness  with  which  they  are  afterward  followed,  are 
points  that  tend  to  increase  or  to  nullify  their  value  regarding  this  con- 
dition. What  may  be  considered  justifiable  grounds  for  emptying  the 
uterus  by  one  authority  may  not  be  so  regarded  by  another.  The  physi- 
cian who  routinely  recommends  intervention  in  all  cases  will  naturally 
be  able  to  show  better  figures  regarding  maternity  mortality  than  will 
the  one  who  waits  for  the  onset  of  an  exacerbation  before  emptying  the 
uterus.  Pradella  (quoted  by  Schauta37)  attempted  to  classify  his  cases 
of  pregnancy,  regardless  of  their  degree  of  advancement,  according  to 
the  extent  of  their  pulmonary  lesion.  He  found  that,  in  the  first  stage 
of  tuberculosis,  emptying  of  the  uterus  had  a  beneficial  effect  in  89  per 
cent  of  cases,  in  the  second  stage  in  83  per  cent,  and  in  the  third  stage 
in  25  per  cent.  In  cases  of  tuberculosis  in  the  first  stage  and  less  than 
one  month  pregnant,  Pradella  found  that  the  induction  of  abortion  was 
successful  in  91  per  cent  of  all  cases.  Kaminer  (quoted  by  Schauta37) 
takes  a  more  pessimistic  view.  He  states  that  he  has  never  seen  a  cure, 
but  believes  abortion  to  be  of  value  in  the  early  months  of  pregnancy. 
In  moderately  advanced  or  far  advanced  cases,  however,  he  expects  but 
little  success,  but  believes  that  early  abortion  tends  to  limit  the  extent 
of  the  disease. 

The  interruption  of  pregnancy,  even  in  early  cases,  is  not  always 
followed  by  improvement.  Veit,82  Kronig,83  and  von  Rosthorn  60  believe 
in  individualizing  each  patient,  and  hold  that  the  pregnancy  should  be 
interrupted  in  the  early  months  in  the  event  of  untoward  symptoms  aris- 
ing. Veit  82  very  properly  declares  that  successive  abortions  are  quite 
as  injurious  as  one  or  two  pregnancies,  especially  if  the  latter  have  been 
properly  treated.     This  author  has  collected  347  cases,  in  which  abortion 


PREGNANCY  AND  TUBERCULOSIS  267 

was  performed  in  patients  with  active  lesions.  Of  these,  56.7  per  cent 
were  benefited,  and  the  remainder  were  unimproved.  Veit  quotes  von 
Bardeleben  to  the  effect  that  only  50  per  cent  of  the  latter's  active  cases 
were  improved.  He  points  to  the  fact  that  in  active  cases  abortion  may 
be  followed  by  the  development  of  miliary  tuberculosis.  Trembley  84 
reported  29  cases  in  which  abortion  was  performed,  with  one  recru- 
descence. Edgar  85  believes  that  it  is  best  to  assume  the  attitude  of  the 
alarmist  in  these  cases.  Knopf  79  states  that  the  more  of  these  cases  he 
sees,  the  more  inclined  he  is  to  favor  radical  treatment.  Werner  80  re- 
ported 60  cases  operated  upon  in  Wertheim's  clinic.  Of  these,  1  died 
from  hemorrhage,  1  died  of  tuberculosis  4  months  after  leaving  the  hos- 
pital, and  4  were  but  little  benefited.  In  none  of  these  cases  had  the 
pregnancy  advanced  more  than  five  months.  All  had  active  pulmonary 
lesions,  laryngeal  involvement,  were  in  poor  physical  condition,  or  suf- 
fered from  some  other  complication.  Of  25  patients  of  this  series,  all 
of  whom  had  been  operated  upon  not  less  than  one  year  before,  1  died 
of  tuberculosis,  20  were  feeling  well,  and  in  4  the  symptoms  of  the  disease 
were  either  unimproved  or  had  grown  worse. 

Bossi 87  urges  rapid  mechanical  dilatation,  followed  by  curettage, 
and  states  that  40  cases  terminated  by  this  method  before  the  sixth  month 
gave  good  results.  Schrerschewer  88  reports  favorable  results  obtained 
in  10  cases  operated  upon  by  Bumm,  and  in  1  from  the  Marburg  Klinik. 
Hysterectomy  was  performed  in  this  series.  Hoist,89  as  the  result  of  his 
experience,  recommends  abortion  in  all  cases,  if  the  lesions  are  active. 
Schauta37  takes  a  radical  stand,  and  states:  "We  are  of  the  opinion  that 
in  every  case  where  tuberculosis  is  definitely  diagnosed,  the  indication 
is  to  bring  on  abortion.  Inasmuch  as  in  at  least  75  per  cent  of  all  cases 
the  disease  advances  during  pregnancy  or  in  the  puerperium,  and  as  the 
time  for  advancement  is  uncertain,  one  may  proceed  to  treat  it  too  late. 
It  is  preferable  to  sacrifice  the  life  of  the  child,  which  is  in  any  case 
of  doubtful  value  in  the  conditions  present." 

Zirkel,90  on  the  basis  of  Hofmeier's  work,  recommends  the  induction 
of  abortion  if  there  is  a  noticeable  loss  of  weight  or  an  aggravation  of  the 
symptoms,  and  Sergent  91  recommends  that  it  be  induced  only  in  excep- 
tional cases.  Von  Franque  92  believes  that  abortion  should  be  induced 
only  when  it  can  reasonably  be  expected  to  improve  the  patient's  condi- 
tion. Stutz  40  reports  32  cases,  and  recommends  immediate  emptying  of 
the  uterus  in  every  stage  of  tuberculosis  and  in  any  month  of  pregnancy. 
In  75  per  cent  of  the  cases  in  the  first  and  second  stages  of  tuberculosis 
there  was  a  marked  improvement  in  the  objective  symptoms  after  the 
termination  of  pregnancy.     In  patients  in  the  third  stage  the  prognosis  is 


268    GYNECOLOGICAL  AXD  OBSTETRICAL  TUBERCULOSIS 

always  bad.  Von  Bardeleben  32  states  that  there  is  a  mortality  of  2.54 
per  cent  among  incipient  cases,  in  whom  the  uterus  is  emptied  prior  to 
the  fourth  month  of  pregnancy. 

Among  ordinary  cases  from  the  fourth  to  seventh  month  similarly 
treated  the  mortality  is  from  20  to  25  per  cent,  and  in  advanced  cases 
the  death  rate  reaches  50  to  80  per  cent.  Pankow  and  Kupferle  42 
state  that  the  results  in  the  Freiberg  Frauen  Klinik  are  relatively 
good,  if  abortion  is  performed  early,  but  that  a  mortality  of  40  per 
cent  follows  the  operation  when  it  is  performed  in  the  second  half  of 
pregnancy,  and  upon  patients  suffering  from  active  lesions.  Permin  93 
urges  the  early  interruption  of  pregnancy  when  progressive  lesions  are 
present.  Crede  and  Holder  94  believe  that  the  progress  of  the  pulmonary 
condition  can  be  divided  into  two  stages,  the  first  stage  being  marked 
by  an  infiltration  of  the  apices  and  the  parenchyma  of  the  lungs,  and  by 
catarrh  of  the  apices;  the  second,  by  cavity  formation,  the  formation 
of  infarcts,  hemoptysis,  and  infiltration,  sometimes  of  the  entire  lobes. 
In  the  first  stage,  if  the  woman  is  well  nourished,  there  is  no  indication 
for  the  induction  of  abortion.  The  patient  should  be  kept  under  observa- 
tion and  examined  at  intervals  by  an  internist ;  she  should  be  given  sana- 
torium treatment  and  especial  care  during  labor  and  in  the  puerperium, 
and  she  should  not  be  allowed  to  nurse  her  child.  If  the  patient  in  the 
first  stage  is  poorly  nourished,  she  may  become  worse  during  pregnancy ; 
labor  is  likely  to  be  difficult,  and  in  the  puerperium  exacerbations  are 
of  frequent  occurrence.  In  these  latter  cases,  if  the  pregnancy  is  of 
only  a  few  weeks'  duration,  abortion  should  be  induced;  if  it  is  of  more 
than  a  few  months'  duration,  it  should  be  allowed  to  continue.  The 
patient  should  be  under  constant  supervision,  breast  feeding,  and  future 
conception  prevented.  In  the  second  stage  of  the  disease  pregnancy  is 
particularly  dangerous.  In  spite  of  this,  Crede  and  Horder  believe 
that  the  treatment  should  be  the  same  as  that  for  a  poorly  nourished 
woman  in  the  first  stage  of  the  disease.  These  cases  should  be  indi- 
vidualized.    In  borderline  cases  abortion  must  often  be  performed. 

Sellheim  95  reports  the  result  of  operation  upon  10  patients,  none  of 
whom  were  pregnant  more  than  5  months.  The  results  in  all  cases  were 
good.  Stutz  40  reports  15  cases,  14  of  which  were  operated  upon  through 
the  vagina  with  good  results.  Peterson  9G  is  of  the  opinion  that  preg- 
nancy exerts  a  harmful  influence  on  the  course  of  tuberculosis,  less  when 
the  disease  is  of  the  fibroid  type,  and  is  especially  dangerous  if  a  pleurisy 
or  pneumonia  should  develop.  He  recommends  individualizing  all  cases 
and  advises  inducing  a  premature  delivery  in  some  cases.  McPherson  97 
believes  that,  in  every  case  of  incipient  tuberculosis  accompanying  preg- 


PREGNANCY  AND  TUBERCULOSIS  269 

nancy,  the  pregnancy  should  be  terminated.  Jellett 98  believes  that  pul- 
monary tuberculosis  is  not  influenced  unfavorably  by  pregnancy.  Rabnow 
and  Reicher,"  Kohne,100  and  Cohn101  are  of  the  same  opinion.  Rabnow 
and  Reicher  report  a  series  of  10  cases  occurring  in  working  women, 
all  of  whom  had  active  lesions.  Of  these  pregnancies  7  are  reported 
to  have  had  no  injurious  effects.  Cohn  reports  that  of  58  cases,  53 
were  apparently  no  worse  for  their  pregnancies,  and  Kohne  found  the 
same  to  be  true  in  10  out  of  22  cases. 

It  is  worthy  of  note  that  these  writers  do  not  report  having  followed 
their  cases  for  very  prolonged  periods  subsequent  to  childbirth.  Van 
Tussenbroek,102  from  a  study  of  the  mortality  statistics  from  Amster- 
dam and  other  Dutch  cities,  arrives  at  the  conclusion  that  the  mortality 
from  tuberculosis  during  the  first  6  months  of  pregnancy  was  increased; 
during  the  later  months  it  was  diminished  in  such  degree  that  the  two 
were  about  even.  She  found  that  the  mortality  from  tuberculosis  dur- 
ing the  year  following  pregnancy  was  about  equal  to  the  general  mor- 
tality among  tuberculous  women  who  had  not  been  pregnant.  The  gen- 
eral opinion  that  the  death  rate  is  increased  by  pregnancy  is,  therefore, 
not  borne  out  by  this  investigator's  studies. 

These  results  are  not  in  accord  with  the  author's  experience,  or  in 
fact  with  those  of  most  observers.  Permin  93  urges  the  necessity  for 
terminating  pregnancy  when  the  disease  is  advancing.  Williams  °8  as- 
serts that  the  harmful  influence  exerted  by  pregnancy  upon  the  course 
of  tuberculosis  is  generally  conceded.  He  believes  that  abortion  should 
be  performed  on  primiparae  when  the  disease  becomes  manifest  in  the 
early  months  of  pregnancy,  but  admits  that  premature  labor  is  of  little 
value.  Davis  30  treats  his  patients  individually,  and  in  the  early  months 
of  pregnancy  he  empties  the  uterus  on  the  first  symptoms  of  an 
exacerbation  in  previously  mild  or  quiescent  cases.  When  a  patient 
with  an  active  lesion,  who  is  just  holding  her  own,  becomes  preg- 
nant, Davis  believes  that,  in  the  majority  of  cases,  abortion  should  be, 
induced.  The  combined  statistics  of  twenty-one  observers,  comprising 
nearly  1,000  cases,  show  that  JJ  per  cent  of  women  were  benefited  by  the 
induction  of  abortion.     The  percentages  vary  from  20  to  97. 

The  diversity  of  opinion  regarding  the  treatment  of  this  condi- 
tion is  evidence  in  itself  that  no  ideal  plan  has  as  yet  been  evolved.  It 
will  be  noticed,  however,  that  the  general  trend  of  opinion  is  toward 
interruption  of  pregnancy  in  the  early  months  of  gestation,  and  toward 
non-operative  treatment  in  the  second  half.  The  author  believes  that  the 
wise  obstetrician  will  familiarize  himself  with  the  results  obtained  by 
others,  and  carefully  consider  the  source  and  the  methods  employed  in 


270        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

compiling  the  statistics;  that  he  will  then  individualize  his  cases,  and 
empty  the  uterus  only  when  it  is  necessary,  and  will  not  allow  his  natural 
repugnance  to  the  performance  of  this  operation  to  influence  him  to  the 
detriment  of  his  patient.  The  average  obstetric  surgeon's  dislike  to 
performing  abortions  is  not  only  natural,  but  laudable,  and  may  in  some 
instances  be  guided  by  his  religious  belief.  He  may,  however,  comfort 
himself  and  his  patient's  family  by  following  the  advice  of  Pinard,57 
who  emphasizes  the  fact  that  abortion  is  induced  only  to  save  the  mother's 
life,  for,  as  the  mother  will  probably  die  without  operation,  abortion 
must,  therefore,  not  be  viewed  as  murder,  since  the  child  will  perish  if 
the  mother  dies.  Unfortunately  for  this  argument,  in  a  certain  propor- 
tion of  cases  the  mothers  live  at  least  until  the  puerperium  is  reached. 
Furthermore,  even  apparently  unfavorable  cases  may  do  well  without 
intervention. 

Consultation  and  Precautions  to  be  Adopted  Prior  to  Empty- 
ing the  Uterus. — Before  deciding  to  empty  the  uterus,  a  consultation 
should  always  be  held.  If  any  doubt  exists  as  to  the  certainty  of  the 
diagnosis  of  tuberculosis,  an  experienced  internist  should  be  called  in. 
The  services  of  a  competent  bacteriologist  will  prove  an  additional  safe- 
guard. Freund  103  very  properly  believes  that,  in  general,  the  internist's 
duties  should  consist  in  giving  information  to  the  gynecologist  in  regard 
to  the  pulmonary  condition,  but  that  he  should  not  be  the  one  to  decide 
whether  or  not  abortion  should  be  performed,  since  the  obstetrician  or 
the  gynecologist  often  has  greater  experience  in  this  particular.  The 
entire  procedure  should  be  conducted  as  openly  as  possible ;  the  family 
of  the  patient,  and  in  most  cases,  the  patient  herself,  should  be  informed 
of  what  is  about  to  be  done.  No  loophole  for  subsequent  criticism 
should  be  left.  The  prognosis  should  in  all  cases  be  guarded,  for  benefit 
may  not  accrue  from  emptying  the  uterus,  and  the  family  should  be  so 
informed,  and  the  true  state  of  affairs  explained  to  them  as  nearly  as 
possible.     ^Yith  the  patient  herself  a  more  optimistic  view  is  justifiable. 

Choice  of  Operation. — If  having  decided  upon  intervention  and 
having  obtained  consultation,  and  secured  the  consent  of  the  family  and 
of  the  patient,  the  next  question  to  be  determined  is  the  method  of  op- 
eration. No  matter  what  method  is  selected,  the  operation  should  be  per- 
formed by  an  experienced  obstetric  surgeon  in  a  well  equipped  hospital. 

Sterilization  of  the  Tuberculous. — Many  methods  of  operation 
have  been  advised,  some  operators  advocating  the  vaginal  and  others  the 
abdominal  route.  Some  advocates  of  the  former  method  and  many  of 
the  latter  recommend  sterilization  of  the  patient  by  one  method  or  an- 
other, for  the  purpose  of  preventing  future  conception.     Among  these 


PREGNANCY  AND  TUBERCULOSIS  271 

are  Sellheim,95  Stutz,40  Werner,86  von  Franque,92  Schottelius,104 
Hohne,105  Ebeler,65  von  Bardeleben,32  Martin,106  Pankow  and  Kup- 
ferle,42  Schauta,37  Kunreuther,54  and  others.  Many  operators  also  ad- 
vise excising  the  placental  site.  The  author  believes  that  routine  steriliza- 
tion is  entirely  unjustifiable,  regardless  of  the  method  employed.  Cer- 
tainly, in  the  average  case  in  which  the  uterus  is  emptied  there  is  some 
hope  of  effecting  a  cure  of  the  tuberculosis.  Some  operators  advise  the 
performance  of  a  type  of  operation  that  permits,  if  it  should  be  desired 
at  a  subsequent  time,  of  the  reconstruction  of  the  genital  tract,  so  that 
conception  may  take  place.  Gauss  107  recommends  effecting  steriliza- 
tion by  means  of  the  X-rays.  It  is  claimed  for  the  X-rays  that  they  may 
be  applied  so  as  to  produce  either  temporary  or  permanent  sterilization. 
Pincus  108  employs  atmocausis  for  the  purpose  of  producing  sterilization. 
Without  being  influenced  by  a  desire  to  evade  the  responsibility  of  the 
operation  of  sterilization,  it  is  better  to  place  the  responsibility  of  preg- 
nancy upon  the  woman  or  upon  her  husband  by  advising  them  to  avoid 
subsequent  pregnancies,  unless  the  pulmonary  condition  improves  suffi- 
ciently to  permit  pregnancy  to  be  carried  out  with  a  reasonable  degree 
of  safety.  The  operation  of  sterilization  necessitates  opening  the  peri- 
toneal cavity  and  prolongs  the  operative  procedure,  two  factors  that  can- 
not fail  materially  to  increase  the  mortality  incident  to  the  operation. 
Dice  81  advises  that  the  surgeon  safeguard  himself  from  subsequent  crit- 
icism or  legal  responsibility  by  obtaining  a  written  agreement  from  the 
parties  concerned  before  sterilizing  the  patient. 

Anesthesia. — The  question  of  inducing  anesthesia  is  of  vital  im- 
portance in  these  cases,  and  will  be  dealt  with  in  detail  in  a  subsequent 
chapter.  It  will  suffice  here  to  state  that  in  every  case  of  very  early  preg- 
nancy— under  4  or  6  weeks — curettage  can  often  be  performed  without 
the  aid  of  an  anesthetic,  a  hypodermic  injection  of  a  1/4  grain  of  morphin 
and  1/150  grain  of  scopolamin  often  being  sufficient  for  the  purpose. 
If  the  patient  is  a  highly  nervous  woman,  a  few  whiffs  of  nitrous  oxide 
gas  may  be  necessary.  When  performing  this  operation  upon  a  con- 
scious patient,  the  author  has  sometimes  employed  a  weak  solution  of 
cocain  or  eucain  applied  to  the  cervical  canal  by  means  of  cotton  soaked 
in  the  solution.  In  inactive  cases  Anderes  109  reports  that  at  the  Zurich 
clinic  chloroform  and  oxygen  in  combination  is  employed,  and  in  the 
presence  of  active  lesions,  spinal  anesthesia  is  used  with  excellent  results. 
As  a  general  anesthetic  nitrous  oxide  gas  should  be  the  choice.  The 
anesthetic  must,  however,  be  carefully  administered. 

Technic  for  Emptying  of  the  Uterus  Prior  to  the  End  of 
the  Second  Month  of  Pregnancy. — Prior  to  the  eighth  or  ninth 


2J2        GYXECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

week,  curettage  is  the  operation  of  choice,  the  uterus  being  emptied  as 
nearly  as  possible  at  one  sitting.  If  the  cervix  is  unusually  rigid,  a 
preliminary  cervical  pack  of  gauze  may  be  employed  for  from  twelve 
to  twenty-four  hours  prior  to  the  operation.  Since  the  operation  should 
be  as  complete  as  possible,  thorough  dilatation  of  the  cervix  is  to  be 
obtained.  Thorough  dilatation  increases  the  speed  with  which  the  op- 
eration may  be  performed,  and  also  conserves  the  blood.  The  latter  is 
of  especial  importance,  and  as  no  bleeding  occurs  until  the  dilatation 
is  completed,  this  procedure  should  be  thoroughly  performed.  After 
the  uterus  is  empty,  or  as  nearly  empty  as  seems  advisable,  a  gauze  pack 
should  be  inserted.  Shortly  before  the  completion  of  the  operation 
ergotin  or  pituitrin  may  be  administered.  The  pack  may  be  removed  in 
about  five  minutes,  and,  if  little  bleeding  occurs,  it  need  not  be  reintro- 
duced. In  the  majority  of  cases,  however,  more  or  less  oozing  will  con- 
tinue, and  as  it  is  highly  important  that  the  blood  be  conserved,  the  pack 
should,  under  such  circumstances,  be  reintroduced,  special  care  being 
taken  to  pack  the  fundus  of  the  uterus  firmly.  Carelessness  in  this  re- 
spect may  result  in  a  firm  stopper  of  gauze  in  the  lower  uterine  segment, 
above  which  more  or  less  blood  may  accumulate.  The  pack  should 
be  removed  within  twenty-four  hours.  Any  remnants  of  membrane, 
etc.,  that  may  have  escaped  the  curet  usually  come  away  with  the  gauze 
at  this  time.  It  is  generally  advisable  to  administer  ergot  or  ergotin 
at  six-hour  intervals  for  the  first  twenty-four  or  thirty-six  hours  sub- 
sequent to  the  operation.  The  Fowler  position  is  beneficial,  materially 
aiding  by  gravity  in  the  drainage  of  the  uterus.  If  it  is  not  employed, 
or  if  there  is  an  extreme  retrodisplacement  of  the  uterus,  the  patient 
should  be  encouraged  to  turn  frequently  upon  her  side  or  her  face, 
thereby  aiding  uterine  drainage. 

Thorough  emptying  of  the  uterus  at  the  time  of  operation  is  far 
preferable  to  simple  breaking  up  of  the  gestation  sac,  and  means  a 
more  rapid  convalescence  and,  in  the  long  run,  the  conservation  of 
blood. 

Convalescence. — At  the  end  of  twenty-four  hours,  or  immediately, 
if  the  weather  conditions  permit,  the  patient  should  be  removed  out  of 
doors  and  the  hygienic  and  dietary  treatment  suitable  for  pulmonary 
tuberculosis  continued.  If  the  operation  has  been  complete,  the  patient 
can  usually  be  out  of  bed  by  the  fifth  day;  if  the  gestation  has  been 
an  early  one,  she  may  leave  her  bed  the  third  day,  provided  no  compli- 
cations have  arisen  and  the  pulmonary  condition  permits. 

Technic  of  Operation  After  Pregnancy  Has  Advanced  Be- 
yond the  Second  Month. — Vaginal  hysterotomy  is  as  a  rule  the  most 


PREGNANCY  AND  TUBERCULOSIS  273 

satisfactory  operation  for  emptying  the  uterus.  It  is  performed  as 
follows :  The  field  is  prepared,  as  for  any  vaginal  operation.  The 
cervix  is  pulled  down,  the  bladder  stripped  off  by  blunt  dissection, 
using  the  fingers  wound  with  dry  gauze  until  the  peritoneum  comes 
into  view.  The  peritoneal  cavity  is  not  opened.  At  this  stage  it  is 
advisable  to  administer  a  hypodermic  of  ergotin.  The  cervix  is  then 
split  in  the  median  line.  The  membranes  then  bulge  into  the  wound 
and  are  incised.  The  amniotic  liquor  is  evacuated  and  the  fetus  is 
delivered.  A  large  gallstone  forceps  applied  to  the  fetal  head  is  an 
excellent  instrument  with  which  to  accomplish  this  step  of  the  opera- 
tion. A  little  care  at  this  point  of  the  operation  will  save  much  time. 
If  the  fetus  is  decapitated  or  an  attempt  is  made  to  remove  it  piece- 
meal, much  time  is  lost.  After  the  delivery  of  the  fetus,  the  placenta 
and  membranes  can  be  easily  removed  manually.  The  cervix  is  sewn 
up  with  interrupted  No.  1  catgut  sutures,  and  the  vaginal  mucosa  su- 
tured in  its  original  position.  The  uterus  is  then  replaced  manually 
in  its  normal  position  and  the  patient  catheterized.  To  guard  against 
unnecessary  loss  of  blood,  traction  should  be  made  upon  the  cervix 
continuously,  the  operator  depending  as  much  as  possible  upon  blunt 
dissection.  It  is  important  that  the  operation  be  confined  as  much  as 
possible  to  the  median  line,  as  thus  a  less  vascular  field  is  encountered. 
Few  ligatures  will  be  required,  although  hemostasis  should  be  thor- 
oughly carried  out.  In  one  instance,  in  the  case  of  a  firm  unyielding 
vaginal  outlet  with  a  high  cervix,  which  could  not  be  brought  down, 
in  an  elderly  primipara,  the  writer  employed  episiotomy,  choosing  this 
operation  in  preference  to  working  through  a  small,  unyielding  opening 
that  would  have  prolonged  materially  the  vaginal  hysterotomy. 

The  after  care  of  these  patients  is  the  same  as  that  advised  for 
those  upon  whom  curettage  has  been  performed.  The  patients  are  out 
of  bed  on  the  fifth  day.  The  author  has  had  uniform  success  with  this 
operation. 

The  operation  requires  from  fifteen  to  twenty  minutes,  and  it  is 
surprising  how  little  bleeding  occurs.  A  preliminary  dose  of  morphin, 
sometimes  supplemented  with  scopolamin,  is  advisable.  The  patient 
should  be  placed  in  the  lithotomy  position,  and  the  vagina  and  ex- 
ternal genitalia  prepared  for  operation  prior  to  the  administration  of 
the  anesthetic.  (See  Chapter  on  Anesthesia  in  Pulmonary  Tubercu- 
losis.) 

This  operation  has  these  advantages,  that  there  is  little  bleeding, 
that  the  uterus  can  be  completely  emptied  at  the  time  of  operation,  that 
there  is  no  subsequent  oozing  from  the  uterus,  and  convalescence  is 


274        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

rapid.  The  further  the  pregnancy  is  advanced,  the  more  decided  is 
the  indication  for  vaginal  hysterotomy. 

It  must,  however,  be  remembered  that  emptying  the  uterus  in  this 
class  of  cases  is  only  indicated  when  the  pulmonary  lesions  are  active 
or  advanced.  Both  of  these  are  conditions  which  make  the  adminis- 
tration of  a  general  anesthetic  especially  hazardous.  In  some  cases, 
therefore,  dilatation  of  the  cervix,  and  simple  breaking  up  of  membranes 
and  removal  with  placental  forceps  or  a  large  dull  curette  of  as  much 
as  possible  of  the  products  of  conception,  is  the  safer  plan.  This  oper- 
ation has  the  further  advantage  that  it  can  be  performed  under  a  local 
anesthetic,  or  in  many  cases  without  anesthesia  of  any  kind,  although 
the  preliminary  administration  of  morphin  and  scopolamin  facilitates 
the  procedure.  The  disadvantages  of  this  operation  are  that  it  is  almost 
impossible  to  entirely  empty  the  uterus,  and  in  many  cases  nothing  more 
than  breaking  up  of  the  membranes  can  be  accomplished.  The  opera- 
tion is,  therefore,  followed  by  considerable  free  oozing  which  continues 
for  two  or  three  days,  and  in  the  end  results  in  the  loss  of  considerably 
more  blood  than  does  the  vaginal  hysterotomy.  The  uterus  usually  has 
to  be  packed  with  gauze  and  often  it  is  necessary  to  renew  this  pack- 
ing. This  causes  discomfort  to  the  patient  and  adds  to  the  danger  of 
infection.     Furthermore,  the  convalescence  is  prolonged. 

Conservation  of  the  patient's  strength  is  of  special  importance;  the 
prolonged  convalescence,  with  the  loss  of  blood  incident  to  this  operation, 
and  the  danger  of  a  general  anesthetic  necessary  with  the  vaginal  hys- 
terotomy, are  the  factors  which  must  be  weighed  against  each  other  in 
the  choice  of  a  method  of  emptying  the  uterus.  In  the  hands  of  a 
skilled  surgeon  vaginal  hysterotomy  is  in  the  author's  opinion  usually 
the  lesser  of  the  two  evils,  although  cases  will  be  encountered  in  which 
the  mere  breaking  up  of  the  membranes  is  clearly  indicated. 

As  in  all  cases  of  abortion,  retrodisplacement  is  to  be  guarded 
against.  The  same  methods  applicable  to  the  non-tuberculous  patient 
are  satisfactory  in  these  cases. 

The  Treatment  of  Pregnancy  Advanced  Beyond  the  Fifth  Month 
in  the  Tuberculous. — As  a  general  principle,  it  may  be  stated  that  when 
the  pregnancy  has  advanced  beyond  the  fifth  month,  little  benefit  will  be 
derived  by  the  patient  from  the  induction  of  abortion,  since  in  any 
event  the  most  dangerous  period  for  the  pregnant  tuberculous  woman 
will  not  be  avoided.  The  puerperium  will  occur  in  any  event,  and  the 
interruption  of  pregnancy  in  many  cases  only  means  shortening  the  life 
of  the  patient,  for  in  advanced  cases  death  is  likely  to  occur  at  this 
time.     Furthermore,  although  the  life  of  the  child  is  still  of  secondary 


PREGNANCY  AND  TUBERCULOSIS  275 

importance  to  that  of  the  mother,  nevertheless  from  the  fifth  month  on, 
the  fetus  must  receive  more  consideration  than  in  the  early  months  of 
gestation.  After  the  fifth  month  of  pregnancy,  little  can  be  accom- 
plished beyond  enforcing  a  strict  general  hygienic  and  dietary  regime, 
and  adopting  the  general  treatment  usually  employed  for  the  tubercu- 
lous. The  indications  for  treatment  are  along  general  lines  and  every 
effort  must  be  made  to  maintain  the  patient's  strength  and  to  improve  her 
general  health.  Such  patients  are  best  treated  in  a  sanatorium  until 
the  time  for  labor  approaches.  In  mild  or  moderately  advanced  cases 
miscarriage  or  premature  labor  rarely  occurs,  but  in  advanced  cases  pre- 
mature labor  is  not  uncommon.  As  the  time  for  delivery  approaches, 
it  is  usually  preferable  to  place  these  patients  in  a  maternity  hospital. 

Some  patients  may  stand  the  last  few  months  of  pregnancy  well, 
but  the  risks  are,  however,  great.  In  desperate  cases,  as  a  rule,  the 
mother's  condition  is  of  secondary  importance,  as  she  is  doomed  in 
any  event,  and  every  effort  should  be  directed  toward  establishing  the 
well  being  of  the  child.  The  author  has  previously  advanced  the  opin- 
ion that  the  high  mortality  among  the  infants  of  tuberculous  mothers  is 
due  not  to  any  congenital  infection  or  special  predisposition,  but  is 
chiefly  the  result  of  improper  surroundings,  faulty  hygiene,  bottle  feed- 
ing, and  the  motherless  condition  of  these  children. 

Delivery  of  Tuberculous  Patients. — Attention  has  been  previously 
directed  to  the  dangers  of  labor  for  the  patient  suffering  from  pulmonary 
tuberculosis.  To  recapitulate,  chief  among  these  are  muscular  exertion, 
exhaustion,  increased  and  sudden  changes  in  the  blood  pressure,  the 
possibility  of  breaking  down  healed  or  partially  healed  pulmonary 
lesions,  resulting  in  the  liberation  of  virulent  tubercle  bacilli  into  the 
blood  stream,  edema  of  the  lungs,  and  the  squeezing  out  of  organisms 
into  the  general  circulation  from  the  placental  site  and  hemoptysis. 
Polak  and  Matthews49  state  that  mild  cases  going  to  term  may  be  com- 
pleted without  causing  alarm,  while  in  advanced  cases  labor  may  be 
tedious,  prolonged  and  fraught  with  many  dangers  to  the  mother,  as, 
e.g.,  dyspnea,  cough,  hemoptysis,  impending  cardiac  failure,  pulmonary 
edema,  pneumothorax,  and,  rarely,  general  dissemination  of  the  infection 
through  the  lungs.  These  authors  state  that  mild  inactive  pulmonary 
tuberculosis  seems  to  have  no  effect  per  se  upon  the  puerperium,  hemor- 
rhage is  no  greater  and  involution  is  not  retarded.  In  the  more  ac- 
tive and  progressive  cases,  there  is  apt  to  be  excessive  hemorrhage,  and 
involution  may  be  tardy.  These  ill  effects  are  no  doubt  due  to  the 
general  asthenic  condition  of  the  woman  at  this  time.  With  these  dan- 
gers in  mind,  the  general  principles  of  the  conditions  of  labor  and  de- 


276        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

livery  can  readily  be  formulated.  The  delivery  should  be  conducted 
with  two  ends  in  view,  the  birth  of  a  living  child,  and  the  expenditure 
of  as  little  physical  exertion  and  strain  on  the  part  of  the  mother  as  pos- 
sible. Mild  cases  may  stand  labor  well,  but  advanced  cases  are  likely 
to  be  complicated  by  dyspnea,  cough,  hemoptysis,  pulmonary  edema, 
cardiac  collapse,  and  pneumothorax.  If  the  general  condition  is  weak- 
ened, labor  is  slower,  and  the  second  stage  is  likely  to  be  prolonged. 

Occasionally,  in  patients  desperately  ill,  it  may  be  necessary  to  in- 
duce premature  labor  in  the  interests  of  the  child. 

In  the  mild  quiescent  case  induction  of  premature  labor  is  rarely  indi- 
cated unless  some  obstetric  complication  exists,  such  as  a  contracted 
pelvis,  etc.  It  should,  however,  be  remembered  that  a  decided  effort 
should  be  made  to  shorten  labor  and  to  make  it  as  easy  as  possible  for 
the  woman.  With  these  points  in  view,  premature  labor,  like  the  in- 
duction of  abortion,  should  be  performed  after  the  seventh  month 
for  a  lesser  degree  of  obstetric  complication  than  it  should  be  in  the 
non-tuberculous  woman.  Furthermore,  these  patients  should  not  be  per- 
mitted to  go  beyond  the  time.  The  induction  of  labor  can  be  per- 
formed without  anesthesia,  and  does  not  in  itself  aggravate  the  pul- 
monary lesion.  It  is,  therefore,  indicated,  if  the  patient  does  not  fall 
into  labor  at  term,  as  the  patient  is  thus  spared  the  obstetric  difficulties 
attendant  upon  the  delivery  of  an  oversized  child.  In  cases  exhibiting 
evidence  of  activity  of  the  pulmonary  lesion  the  induction  of  labor  two 
weeks  before  term  is  generally  advisable. 

Cesarean  Section. — This  operation  may  be  indicated  as  a  life  saving 
measure  for  the  mother  or  for  the  child.  In  one  case  the  author  per- 
formed cesarean  section  on  a  mother  nearly  at  term,  who  had  advanced 
bilateral  ulcerative  pulmonary  lesions  and  who,  during  the  last  month 
or  two  of  pregnancy,  suffered  from  frequent  profuse  hemoptysis. 
Slight  coughing  or  exertion  often  produced  marked  hemorrhages.  Four 
weeks  before  the  date  of  her  expected  accouchement  this  patient  was 
removed  from  The  Henry  Phipps  Institute,  where  she  had  been  bedfast 
for  two  months.  Almost  the  first  labor  pains  produced  a  hemorrhage. 
Cesarean  section  under  spinal  anesthesia  was  performed  without  loss 
of  time,  and  a  living  infant  was  the  result.  The  mother  survived  the 
operation  nine  months.  In  this  case  it  is  almost  certain  that,  without 
operation,  the  mother  would  have  died  during  the  first  stage  of  labor, 
and  the  infant  would  also  have  been  sacrificed.  The  author  has  on  two 
occasions  performed  cesarean  section  strictly  in  the  interest  of  the 
child.  In  the  first  of  these  cases  the  mother  was  almost  moribund ; 
spinal  anesthesia  was  employed,  and  the  patient  died  while  the  abdominal 


PREGNANCY  AND  TUBERCULOSIS  277 

wall  was  being  incised.  The  second  case  was  one  of  advanced  bilateral 
ulcerative  lesions  with  frequent  hemorrhages.  This  patient  was  in  the 
worst  possible  physical  condition,  and  it  seemed  certain  that  the  physical 
exertion  of  labor,  no  matter  how  guarded,  would  result  in  death  of  the 
woman.  The  heart  sounds  were  fairly  good,  and  cesarean  section 
under  spinal  anesthesia  was  performed.  The  woman  survived  the  oper- 
ation three  months.  In  both  instances,  the  infants  were  fortunately 
saved,  both  were  well  and  apparently  normal  when  six  months  old. 
Cesarean  section  should  be  performed  only  in  desperate  cases. 

In  the  average  case,  the  general  indications  are  especial  care  and 
symptomatic  treatment  in  the  first  stage  of  labor,  and  the  use  of  the  for- 
ceps during  the  second  stage.  Preparations  for  a  rapid  delivery  should 
be  made  and  the  instruments  sterilized  and  the  operating  room  in 
condition,  so  that  an  immediate  operative  delivery  can  be  performed 
at  any  stage,  if  it  should  become  necessary.  Assistants  and  nurses 
should  be  at  hand.  The  author  believes  that  even  the  shock  of  a  cesa- 
rean section  is  preferable  to  permitting  a  pulmonary  edema  to  become 
advanced.  Naturally,  such  an  operation  should  be  performed  only  in 
the  first  stage  of  labor,  and  only  under  very  exceptional  circumstances. 
As  a  rule,  no  such  radical  measures  are  required. 

If  edema  of  the  lungs  sets  in,  labor  must  be  terminated  without 
delay,  if  either  the  mother  or  the  child  is  to  be  saved.  In  the  event  of 
such  an  occurrence  in  the  second  stage  of  labor,  extraction,  either  with 
the  aid  of  forceps  or  by  version,  should  be  performed.  No  time  should 
be  lost,  but  the  child  should  not  be  sacrificed  by  too  great  haste.  It  is 
likely  that,  in  any  event,  the  mother  is  doomed.  The  author  makes  it 
a  routine  measure  in  these  cases,  as  soon  as  the  labor  pains  become 
pronounced,  to  inhibit  them  with  doses  of  morphin  sulphate,  usually 
gr.  1/16,  given  at  frequent  intervals  to  overcome  at  least  the  extreme 
severity  of  the  pains.  In  no  event  should  the  drug  be  pushed  to  its 
physiologic  limit.  In  a  few  cases  a  modified  twilight  sleep  has  been 
employed.  After  the  completion  of  the  first  stage,  operative  delivery 
is  generally  indicated ;  at  such  times  it  may  be  necessary'  to  administer 
the  hypodermic  more  frequently,  and  occasionally  even  a  few  whiffs  of 
nitrous  oxide  may  be  given.  The  latter  should,  however,  be  avoided 
if  possible.  Nevertheless,  in  most  cases  brief,  light  anesthesia  is  pref- 
erable to  a  prolongation  of  hard  labor.  In  order,  as  much  as  possible, 
to  minimize  the  dangers  of  a  congenital  infection  in  the  child  through 
the  squeezing  out  of  tubercle  bacilli  that  may  be  present  in  the  placenta, 
the  cord  should  be  ligated  as  soon  as  possible,  and  the  interval  of  waiting 
for  cessation  of  pulsation  omitted. 


278        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Puerperium. — If  the  weather  conditions  are  at  all  favorable,  the 
puerperium  should  be  passed  out  of  doors.  In  any  event,  the  break- 
in  the  regular  hygienic  regime  incident  to  labor  should  be  as  short  a 
one  as  possible.  Every  effort  should  be  directed  toward  improving  the 
patient's  general  condition  and  maintaining  her  resisting  powers.  As 
soon  as  possible  the  patient  should  be  removed  to  a  well  conducted  sana- 
torium. Unfortunately,  this  is  attainable  only  in  a  small  proportion  of 
cases.  For  the  intelligent,  and  for  those  willing  and  able  to  adopt 
the  proper  hygiene  and  obtain  efficient  medical  supervision,  this  is  less 
necessary.  It  is,  however,  the  poor  and  ignorant  who  especially  require 
sanatorium  treatment,  and  these  are  the  patients  who  are,  as  a  rule, 
unable  to,  and  in  some  cases  unwilling  to,  profit  by  it. 

Nursing. — Breast  feeding  should  be  forbidden,  and  the  infant 
should  be  kept  in  a  separate  and  preferably  distant  room  from  the 
mother.  Although  this  may  be  a  great  hardship  for  the  Woman,  the 
less  she  sees  of  the  child  the  better  it  is  for  it.  The  infant  is  put  at 
once  upon  the  bottle  with  a  suitable  milk  mixture,  or  given  a  foster 
mother.  The  only  treatment  the  mother's  breast  requires  is  a  support- 
ing bandage.  This  need  not,  and  in  fact  should  not,  be  too  tightly 
applied.  For  the  first  day  or  two  after  the  milk  comes  the  breast  will 
feel  heavy  and  full.  In  a  small  proportion  of  cases  this  will  be  more 
than  a  discomfort,  and  will  amount  to  actual  pain;  in  the  latter  case  a 
few  small  doses  of  morphin  may  be  administered.  An  ice  bag  over  the 
breasts  usually  does  much  to  diminish  the  discomfort.  After  the  second 
or  third  day  following  the  appearance  of  the  milk,  no  further  discom- 
fort is  experienced,  the  flow  of  milk  ceases  and  involution  of  the  breasts 
sets  in.  Under  no  circumstances  should  massage  or  the  breast  pump 
be  employed.  These  merely  tend  to  prolong  the  period  of  discomfort. 
Tight  bandaging  increases  the  discomfort  and  has  no  effect  upon  the 
milk  secretion.  Belladonna  and  other  local  applications  of  similar  char- 
acter are  of  doubtful  value.  A  dose  or  two  of  Epsom  salts  and  mod- 
erate restriction  of  liquids  are  probably  of  benefit  and  may  be  employed 
for  a  day  or  two. 

The  Influence  of  Pregnancy  upon  Tuberculous  Lesions  Other 
Than  Those  of  the  Lungs. — Tuberculous  lesions  other  than  those  of  the 
lungs  are  frequently  secondary  infections,  the  primary  focus  being 
often  situated  in  the  lungs.  For  this  reason  a  careful  examination  of 
the  lungs  should  be  made  in  every  case.  A  negative  chest  examination 
and  history,  although  it  does  not  exclude  a  pulmonary  lesion,  at  least 
shows  that,  if  such  a  lesion  is  present,  it  is  of  limited  extent  and  inactive 
and  for  practical  purposes  is  not  of  sufficient  gravity  to  influence  the 


PREGNANCY  AND  TUBERCULOSIS  279 

prognosis  very  materially.  Its  possible  existence  should,  however,  be 
borne  in  mind,  and  an  examination  made  at  regular  intervals  to  de- 
termine the  pulmonary  condition.  In  general,  tuberculous  lesions  other 
than  those  of  the  lungs  are  less  affected  by  pregnancy  than  are  pul- 
monary lesions. 

Tuberculosis  of  the  osseous  system  is  but  little  influenced  by  preg- 
nancy. Pinard  57  states  that  he  has  never  seen  a  case  of  bone  tubercu- 
losis aggravated  by  pregnancy.  The  author  has  seen  a  number  of  such 
cases,  including  lesions  of  the  hip  and  spine,  none  of  which  has  been 
unfavorably  influenced  by  pregnancy. 

Tuberculous  peritonitis,  by  involving  the  pelvic  peritoneum,  fre- 
quently results  in  sterility.  Indeed,  these  patients  are  so  ill  that  inter- 
course does  not  generally  take  place,  and  it  follows  that  pregnancy  is 
rare.  Peritonitis  may,  however,  develop  during  the  course  of  preg- 
nancy, but  even  here  it  does  not  appear  to  be  of  a  more  severe  type  than 
in  the  non-pregnant.  Abortion  and  premature  labor  are  not,  however, 
infrequent.  Schmidt 110  has  recorded  the  results  obtained  from  the  oper- 
ative treatment  of  37  cases  of  peritoneal  or  genital  tuberculosis,  and  in 
each  case  these  results  were  excellent.  Delassus  1X1  reports  the  history 
of  a  remarkable  case.  The  patient,  who'  was  29  years  of  age,  was  op- 
erated upon  for  a  tuberculous  peritonitis.  Later,  the  abdomen  was 
opened  during  the  course  of  a  herniotomy,  at  which  time  the  peritoneal 
condition  was  found  to  be  improved.  Eighteen  months  later  she  was 
delivered  spontaneously  of  an  8-pound  infant.  Benestad  112  has  re- 
corded the  history  of  a  case  of  acute  tuberculous  peritonitis  occurring 
during  the  puerperium.  Oppenheimer  113  states  that  women  who  have 
had  a  nephrectomy  performed  for  renal  tuberculosis  and  subsequently 
become  pregnant  run  a  decided  risk  not  only  of  kidney  insufficiency, 
but,  if  a  tuberculous  cystitis  persists,  the  infection  may  spread  rapidly 
to  adjacent  organs.  Esch  (quoted  by  Davis30)  has  seen  such  patients 
stand  the  strain  of  pregnancy  well.  Davis  reports  a  case  in  which 
eclampsia  occurred.  The  patient  survived,  however,  and  was  in  good 
condition  one  month  later. 

Treatment. — As  a  general  rule,  cases  of  tuberculosis  affecting  other 
portions  of  the  body  than  the  lungs  should  be  treated  along  general  sur- 
gical lines.  In  all  cases  hygienic  and  dietary  measures  are  of  prime 
importance.  From  the  surgical  aspect,  intervention  may  be  required. 
In  the  event  of  an  acute  exacerbation  of  the  lesion,  the  induction  of 
abortion  may  be  indicated,  just  as  it  may  in  any  other  disease.  The 
benefits  to  be  derived  from  it  are,  however,  much  more  questionable 
than  when  the  lungs  are  attacked.     Should  pulmonary  symptoms  be- 


280        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

come  manifest,  the  treatment  is  the  same  as  that  previously  suggested 
under  the  head  of  pulmonary  tuberculosis  and  pregnancy.  During 
labor  the  cases  should  be  carefully  guarded  and  every  effort  made  to 
conserve  the  patient's  strength.  To  this  end,  forceps  should  usually  be 
employed  during  the  second  stage  of  labor  and  measures  be  taken  to 
prevent  undue  exertion  and  exhaustion.  As  a  general  rule,  these  moth- 
ers should  not  nurse  their  infants ;  the  safer  plan,  for  both  mother  and 
child,  is  to  institute  artificial  feeding  at  once. 


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sur  la  marche  de  phthisic     Paris,  1856. 

10.  Warren,  E.     The  Influence  of  Pregnancy  on  the  Development 

of  Tuberculosis.  Philadelphia,  185 1.  Also  same  paper  under 
title  Does  Pregnancy  Accelerate  or  Retard  Development  of 
Tuberculosis  of  the  Lungs  in  Persons  Predisposed  to  This 
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Philadelphia  and  London,  1913.     P.  107. 

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p.  416. 

19.  Bacon,  C.  S.     Jr.  Am.  Med.  A.     1913.     61  750. 

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1914.     p.  347. 

24.  Wiessner,   M.     Uber   das  Verhalten   des   Blutdruckes   wahrend 

der  Menstruation.     Leipzig,  1904. 

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26.  Dietrich.     Arch.  f.  Gyn.     191 1.     94:394. 

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London,  19 13. 

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31.  Friedrich,  M.     Arch.  f.  Gyn.      1913.      101  :376. 

32.  von   Bardeleben,   H.      Deutsch.    Med.    Woch.      191 1.     p.    764. 

Also,  Berl.  Klin.  Woch.     1912.     No.  37. 

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1912. 

37.  Schauta,  F.    Monschr.  f.  Gebh.  u.  Gyn.     191 1.    33:265. 

38.  Funk,  E.  H.     Med.  Clin.  No.  Am.     1918.     2:803.     Also,  Ther. 

Gaz.     1915.     39:I58- 

39.  Maragliano.     Gac.  d.  osp.     1899.     14:1193,  1225. 

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6 :87. 

41.  Parry,  A.     Am.  Jr.  Obst.     1914.     70:94. 

42.  Pankow,  O.  R.,  und  Kupferle,  L.     Die  Schwangerschaftsunter- 

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43.  Deibel.     Inaug.  Dis.     Heidelberg,   1899. 

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45.  Silberman.     Quoted  by  Malsbary,  No.   14. 

46.  Dirner.     Quoted  by  Malsbary,  No.  14. 


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47.  Glas,  E.,  and  Krause,  E.     Klin-ther.  Woch.     1908.     No.  50. 

48.  Trembley,  C.  C.     Jr.  Am.  Med.  A.     1909.     53:989. 

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51.  Zirkel,  K.     Wurzburg,  1908,  F.  Standeraus. 

52.  Miller  and  Woodruff.    Jr.  Am.  Med.  A.     Mar.  27,  1909. 

53.  Floyd  and  Bowditch.     Bost.  Med.  Surg.  Jr.    Feb.,  19 10. 

54.  Kunreuther,  M.     Berl.  Klin.  Woch.     1914.     51  :i628. 

55.  Armand-Delille.     Am.  Jr.  Obst.     1912.     2:664. 

56.  Kingsford,  L.     Lancet.     Sept.  24.   1904. 

57.  Pinard.     Ann.  de  gyn.  et  d'obst.     June,  191 2. 

58.  Williams,  J.  W.     Obstetrics.     New  York  and  London,  1903. 

59.  Lebirt.    These  de  Paris.     1909. 

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No.  1. 

61.  Reiche.    Munch.  Med.  Woch.    Sept.  19,  191 1. 

62.  Lobenstine.     Am.  Jr.  Obst.     1913.     67:363. 

63.  Merletti.     Arch.  Ital.  di  gin.     1904.     2 14. 

64.  Kamina.    Deutsch.  Med.  Woch.     1901.     35 :587. 

65.  Ebeler,  F.     Prakt.  Ergeb.  d.  Gebh.  u.  Gyn.     1914.     6:87,  443. 

66.  Hoffman.     Pub.  Dep.  Med.  Jefferson  Med.  Coll.     1914. 

67.  Schlimpert.     Arch.  f.  Gyn.    90:121;  1911.    94:863. 

68.  von  Sokolowski,  A.     Ztschr.  f.  Lar.  u.  Rhin.     1909.    2  1575. 

69.  Milligan,  W.     Brit.  Jr.  Tuberc.     19 12. 

70.  Vagni,  D.  A.     Sem.  med.     191 5.     22:24. 

71.  Raspini.     La  gin.     1913.     10:249. 

72.  Imhofer,  R.     Prag.  Med.  Woch.     1914.     39:3. 

73.  Kuttner,  A.     Ann.  des  mal.  de  Tor.,  du  lar.     1907.     33:445. 

74.  Lasogna,  F.     Arch.  ital.  di  otol.     1914.     25  :io. 

75.  Lubliner,  L.     Med.  i  Kron.  lek.     1910.     45  489. 

76.  Auche,  M.  B.     Jr.  de  med.  de  Bordeaux.     1914.     p.  93.    • 
yy.  Palmer,  G.  T.     Jr.  Am.  Med.  A.     1915.     64:1312. 

78.  Schlossmann.    Monschr.  f.  Gebh.  u.  Gyn.     19 13.     17:1311. 

79.  Knopf,  A.     N.  Y.  Med.  Rec.     June,  1906. 

80.  Tissier.     Arch.  mens,  d'obst.  et  de  gyn.     1913.     2 :52. 

81.  Dice,  W.  G.     Am.  Jr.  Obst.     1915.     71  ^97. 

82.  Veit.     Versl.  Deutsch.  Naturf .  u.  Arz.  in  Cassel :  Abt.  f .  Gebh. 

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83.  Kronig.     Versl.   Deutsch.   Naturf.   u.   Arz.    in   Cassel :   Abt.    f . 

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85.  Edgar,  J.  C.     Am.  Jr.  Obst.     1913.     67:363,  discussion. 

86.  Werner,  P.     Zentrbl.  f.  Gyn.     1913.     37:1581. 

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CHAPTER  XII 

MENSTRUAL    DISTURBANCES    IN    CONJUNCTION    WITH    PULMONARY 

TUBERCULOSIS 

Classification  according  to  types — General  considerations — Etiology — Theories  advanced 
— Later  observations — Chief  indication  for  treatment — Dysmenorrhea — Clinical 
reports — Use  of  tuberculin — Scanty  menstruation — Statistics — Irregular  scanty 
flow  —  Amenorrhea  —  Cases  studied  —  Menorrhagia  —  Vicarious  menstruation  — 
Periodic  hemoptysis — Cases  cited — Leukorrhea — Influence  of  menstruation  on 
temperature  in  pulmonary  tuberculosis — Cause — Consideration — Precautions  in- 
stituted— Bibliography. 


GENERAL  CONSIDERATIONS 

Menstrual  disturbances  frequently  occur  in  conjunction  with  pul- 
monary tuberculosis.  As  a  general  thing,  they  tend  towards  a  lessening 
of  the  loss  of  blood,  increase  in  pain,  or  both.  The  disposition  towards 
a  scanty  flow  may  occur  at  any  time  during  the  course  of  the  pulmonary 
disease,  but  is  most  frequent  in  advanced  or  acute  cases.  Dysmenor- 
rhea, on  the  other  hand,  is  common,  even  in  the  early  stages  of  the  dis- 
ease. In  234  ambulatory  cases  of  pulmonary  tuberculosis  observed  by 
the  author,  all  of  whom  were  free  from  pelvic  disease,  and  whose  ages 
vary  from  17  to  39  years  (the  average  being  28  years),  the  following 
menstrual  disturbances  were  observed  : 

Per  cent 

Normal    23 

Abnormal JJ 

Dysmenorrhea    72 

severe    30 

Scanty  flow,   fairly  regular    53 

Irregular,  scanty   10 

Amenorrhea   5 

Menorrhagia    0.8 

Vicarious  menstruation 0.43 

Macht's  ]  findings  are  in  accord  with  our  own.  Classified  according 
to  the  ordinary  types  of  menstruation,  Macht  found  : 

284 


MENSTRUAL    DISTURBANCES  285 

Per  cent 

Regular,  no  change  in 51.6 

Amenorrhea  (scanty  or  complete)    27.3 

Irregular  (some  menorrhagia  or  amenorrhea)   8.3 

Menorrhagia    4.6 

Pregnant  (in  which  amenorrhea  could  be  ac- 
counted for  on  grounds  other  than  tuber- 
culosis)        4.4 

Menopause  (artificial  or  otherwise)    3.8 

In  considering  the  menstrual  disturbances  resulting  from  pulmonary 
tuberculosis,  it  is  important  to  remember  that  even  in  the  normal  woman 
the  standard  is  a  variable  one;  what  is  normal  for  one  individual  may 
readily  be  abnormal  for  another.  Dysmenorrhea  is  also  a  relative  symp- 
tom, the  amount  of  pain  which  will  keep  one  patient  in  bed  may  be  but 
little  complained  of  by  another.  The  patients  comprising  our  series 
have  all  been  personally  interviewed  by  the  writer  and  particular  care 
has  been  exercised  to  obtain  an  accurate  menstrual  history.  It  should 
be  stated  that  some  of  the  cases  of  diminished  flow  gave  a  history  of 
a  previous  period  of  increase  in  flow,  as  a  rule  preceding  for  a  short 
period  the  lessening  of  the  flow. 

Etiology. — Before  considering  in  detail  the  various  menstrual  dis- 
turbances, a  study  of  their  etiology  is  advisable.  At  the  outset  it  must 
be  remembered  that  not  only  are  many  of  these  symptoms,  such  as 
dysmenorrhea,  scanty  flow  and  menorrhagia,  relative  symptoms,  for 
which  the  normal  standard  can  be  obtained  only  by  studying  the  indi- 
vidual patient,  but  also  that,  even  when  pathologic  in  their  degrees, 
they  are  present  more  or  less  frequently  in  otherwise  healthy  non-tuber- 
culous women.  For  this  reason  special  care  must  be  observed  in  classi- 
fying the  various  symptoms,  and  judgment  must  be  exercised  before 
declaring  that  in  any  given  case  the  menstrual  disturbance  is  the  result 
of  tuberculosis.  Needless  to  state,  all  cases  in  which  there  are  distinct 
pelvic  lesions  should,  with  possibly  one  exception,  be  excluded.  The 
possible  exception  is  of  those  cases  of  pulmonary  tuberculosis  suffering 
from  menstrual  disturbances  and  complicated  by  hypoplasia  of  the 
genital  organs.  Whether  or  not  there  is  a  relationship  between  hypo- 
plasia of  the  genital  organs  and  tuberculosis  will  be  considered  sub- 
sequently. 

All  patients  were  excluded  from  this  series  who  were  suffering  from 
a  combination  of  tuberculosis  and  some  other  disease  when  the  char- 
acter of  the  latter  might  in  itself  influence  menstruation. 


285       GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

The  following  theories  have  been  advanced  to  account  for  the 
menstrual  disturbances  which  occur  in  these  patients : 

(i)  Thorn,2  from  a  study  of  uteri  from  tuberculous  patients,  be- 
lieves that  he  has  found  an  almost  uniform  atrophy  of  the  uterus  with 
degenerative  changes  in  the  blood  vessels,  in  general,  similar  to  those 
present  in  the  senile  organ. 

(2)  That  the  menstrual  changes  are  the  result  of  a  toxemia  or 
analogous  condition,  which  reacts  upon  the  ductless  glands,  resulting 
in  ovarian  changes,  either  histologically  or  physically.  Butner  3  believes 
that  the  menarche  of  the  tuberculous  girl  is  delayed  or  absent,  not  be- 
cause of  an  economic  anabolism  or  conservatism  of  nature,  but  rather 
from  a  catabolic  toxin  being  elaborated  by  the  growth  of  the  tubercu- 
losis, which  has  a  selective  action  in  some  unknown  way  over  menstrua- 
tion, probably  by  the  influence  of  the  toxin  on  the  internal  secretion  of 
the  ovary. 

(3)  That  pulmonary  tuberculosis,  when  occurring  im  early  life, 
tends  to  prevent  the  complete  development  of  the  genital  organs,  so 
that  many  of  these  patients  have  hypoplasia  of  the  uterus,  of  the  ovaries, 
or  both. 

(4)  That  the  menstrual  disturbances  are  the  result  of  a  poor  gen- 
eral condition  incident  to  the  tuberculosis,  such  as  anemia,  hydremia, 
general  loss  of  strength,  etc. 

Regarding  the  first  theory,  the  author's  studies  have  not  confirmed 
the  findings  of  Thorn.  The  more  modern  view,  that  in  general  the 
uterus  is  of  secondary  importance  to  the  ovary  in  the  function  of  men- 
struation, is  apparently  based  upon  a  firmer  scientific  basis  than  is  the 
older  view  that  the  uterus  is  chiefly  to  blame  for  abnormal  changes  in 
the  menses. 

In  regard  to  the  second  theory,  De  Jong  4  has  studied  the  ovaries 
from  a  large  series  of  tuberculous  women  and  finds  the  external  appear- 
ance of  the  ovary  in  these  patients  to  be  variable;  it  may  be  smooth  or 
furrowed.  Comparison  of  the  ovaries  of  tuberculous  and  non-tubercu- 
lous women  shows  that  there  is  no  marked  difference  in  size,  but  the 
weight  of  the  former  is  less.  Tuberculosis  does  not  affect  the  number 
of  primordial  follicles,  nor  does  it  destroy  them.  De  Jong  does,  however, 
believe  that  to  some  extent  it  prevents  their  proper  development.  This 
results  in  a  lessened  number  of  corpora  lutea.  This  may,  in  part,  account 
for  the  scanty  menstruations  and  dysmenorrhea  so  common  in  these 
patients,  as  it  is  accepted  that  the  luteum  cells  exert  a  definite  influence 
upon  menstruation. 

Poncet  and  Leriche  5  believe  that  many  of  the  sclerotic  lesions  in 


MENSTRUAL    DISTURBANCES  287 

the  pelvis  are  due  to  tuberculosis  occurring  in  early  life,  such  as  micro- 
polycystic degeneration  of  the  ovaries,  fibrosis  of  the  uterus,  hydro- 
salpinx, and  hypoplasia.  The  amenorrhea  and  other  menstrual  dis- 
turbances, they  believe,  are  a  direct  manifestation  of  the  disease  and  not 
merely  the  result  of  a  general  dyscrasia. 

Sessa,6  in  the  study  of  the  changes  in  ovaries  of  children  result- 
ing from  infectious  diseases  in  children  under  5  years  of  age,  dead 
of  acute  or  chronic  infectious  diseases,  and  who  had  exhibited  no 
symptoms  suggestive  of  ovarian  disease,  found  no  macroscopic  change 
in  the  ovary.  Microscopically,  more  or  less  pronounced  changes  were 
observed.  In  tuberculous  patients  there  were  generally  interstitial 
changes  with  more  or  less  infiltration  by  chronic  inflammatory  products. 

Grafenberg,7  Schiffman  8  and  others  have  pointed  out  the  frequency 
with  which  underdeveloped  uteri  are  present  in  these  cases,  Hegar, 
Merlitti,9  de  Rouville,10  and  others  have  emphasized  the  frequency  with 
which  genital  tuberculosis  occurs  in  hypoplastic  organs.  As  genital 
tuberculosis  is,  in  90  per  cent  of  cases,  a  secondary  infection,  these 
latter  observations  have  definite  bearing  upon  the  subject  under  dis- 
cussion. 

In  the  entire  series  of  234  cases  constituting  the  author's  study, 
II  patients  had  what  might  be  termed  "infantile  uteri."  Of  these  9 
exhibited  more  or  less  scanty  flow,  and  8  definite  dysmenorrhea.  Hypo- 
plasia of  organs  other  than  the  genital  tract  is  not  especially  frequent 
in  the  tuberculous.  Furthermore,  hypoplasia  in  the  non-tuberculous  is 
relatively  a  frequent  condition.  To  prove  this  theory  it  would,  there- 
fore, be  necessary  to  show  that  hypoplasia  of  the  genital  organs  was 
more  frequent  in  the  tuberculous  than  in  the  non-tuberculous.  Nat- 
urally, hypoplasia  of  the  genital  organs  can  only  be  attributed  to  tuber- 
culosis when  the  infection  has  originated  at  a  period  prior  to  that  in 
which  the  development  of  the  genital  organs  occurs.  The  generally 
accepted  theory  that  many  cases  of  pulmonary  tuberculosis  are  the  re- 
sult of  infection  in  early  life,  and  only  become  manifest  later,  is,  how- 
ever, to  be  considered.  It  appears,  moreover,  improbable  that  hypo- 
plasia of  the  genital  tract  should  be  attributable  to  these  early  infections, 
which  are  inactive.  It  is  possible  that  a  moderately  active  tuberculosis 
occurring  at  a  period  during  or  prior  to  the  development  of  the  genital 
organs  may  have  some  inhibiting  action  on  the  development  of  the 
uterus  or  ovaries.     This,  however,  is  not  yet  proven. 

The  fourth  theory,  that  the  menstrual  disturbances  are  the  result 
of  a  general  malnutrition,  appears  to  afford  the  most  probable  explana- 
tion in  the  majority  of  cases.     It  is  true  that  some  patients,  especially 


288        GYNECOLOGICAL  AXD  OBSTETRICAL  TUBERCULOSIS 

those  suffering  from  dysmenorrhea,  are  often  in  comparatively  good 
condition  and  exhibit  little  anemia.  The  majority  of  tuberculous  pa- 
tients are  distinctively  below  par,  and  often  show  more  or  less  blood 
changes.  Practically  all  the  anemias  produce  menstrual  disturbances. 
The  menstrual  disturbances  usually  accompanying  chlorosis  are  in  gen- 
eral strikingly  similar  to  those  occurring  in  tuberculosis.  All  the  in- 
fectious fevers  are  prone  to  produce  menstrual  changes;  menstrual  dis- 
turbances are,  therefore,  only  what  would  be  expected  in  tuberculosis. 
It  is  probable  that  the  menstrual  disturbances  resulting  from  pulmonary 
tuberculosis  may  be  the  result  of  a  number  of  conditions,  and  that 
either  the  toxemia  theory,  or  the  general  malnutrition  theory  may  be 
applicable  to  certain  cases.  From  our  own  findings  we  attribute  little 
weight  to  the  theory  based  upon  a  hypoplasia  of  the  genital  tract.  In  our 
series  hypoplasia  has  been  present,  but  not  more  frequently  than  might 
be  expected  in  a  series  of  non-tuberculous  patients. 

Especially  is  it  important  to  emphasize  the  fact  that  menstrual  dis- 
turbances are  more  likely  to  occur  in  women  under  35  years  of  age.  If 
the  pulmonary  lesions  become  manifest  after  35  years  of  age,  severe 
menstrual  disturbances  are  less  frequent.  In  those  in  whom  the  tuber- 
culosis has  appeared  earlier,  menstrual  disturbances  are  likely  to  be 
somewhat  lessened  after  this  age.  An  early  menopause  is  frequent  in 
the  tuberculous.  In  tuberculous  girls  the  onset  of  menstruation  is 
often  delayed. 

Treatment. — As  menstrual  disturbance  is  so  frequent  in  the  tubercu- 
lous, these  patients  should  be  especially  guarded  at  the  time  of  the 
flow.  The  chief  indication  for  treatment  in  all  these  cases  should  be 
directed  towards  the  pulmonary  condition,  as  it  follows  that,  if  the 
cause  of  the  disturbance  can  be  improved,  the  menstrual  abnormality 
will  tend  to  improve. 

As  a  general  rule,  they  are  better  in  bed  for  a  few  days  prior  to  the 
flow,  and  for  the  first  day  or  two  of  the  menstrual  period.  The  bowels 
should  be  regulated  with  great  care,  and  if  there  is  a  tendency  towards 
dysmenorrhea,  especially  if  it  is  of  the  congestive  type,  a  brisk  purge 
is  advisable.  In  cases  of  excessive  flow,  care  should  be  observed  to 
conserve  the  strength  by  checking  an  abnormal  loss  of  blood.  With- 
out exception,  all  such  cases  should  be  confined  to  bed  during  the  period 
of  greatest  bleeding.  Unfortunately  many  women  suffering  from  tu- 
berculosis are,  on  account  of  their  social  surroundings,  unable  to  stay 
in  bed  for  two,  three,  or  more  days  each  month.  Nevertheless,  these 
patients  should  be  advised  against  physical  exertion  at  these  periods,  and 
if  they  cannot  stay  in  bed  or  spend  considerable  portion  of  the  time 


MENSTRUAL     DISTURBANCES  289 

upon  a  couch,  should  at  least  endeavor  to  guard  against  undue  exertion. 

Dysmenorrhea. — In  the  series  of  cases  studied  from  which  these 
conclusions  have  been  drawn,  72  per  cent  of  patients  complained  of 
more  or  less  dysmenorrhea.  This  in  itself  is  not  an  unusual  propor- 
tion. The  researches  of  Tobler,11  Schaffer,1-  and  others  have  shown 
that  at  least  70  to  75  per  cent  of  otherwise  normal  women  suffer  more 
or  less  at  the  time  of  the  flow.  Schaffer  found  that  dysmenorrhea 
severe  enough  to  be  classified  as  pathologic  was  present  in  14  per  cent 
of  his  cases.  That  30  per  cent  of  our  series  suffered  from  severe 
dysmenorrhea  is,  however,  excessive. 

This  latter  group,  consisting  of  70  cases,  was  studied  as  to  the  type 
of  dysmenorrhea  present,  with  the  following  results :  5  cases  were  of 
a  purely  obstructive  type  of  dysmenorrhea,  i.e.,  the  pain  appeared  simul- 
taneously with,  or  a  few  hours  before,  the  onset  of  the  flow,  was  cramp- 
like or  expulsive  in  character,  often  simulating  miniature  labor  pains, 
frequently  temporarily  relieved  by  the  expulsion  of  a  clot,  and  was 
most  severe  for  the  first  third  of  the  menstrual  period.  Forty-eight 
were  plainly  congestive  in  type,  i.e.,  the  pain  began  some  time  before 
the  onset  of  the  flow,  in  some  instances  two  or  three  or  more  days,  was 
of  a  dull,  heavy  aching  character,  experienced  over  the  lower  abdomen, 
sides,  and  back,  and  sometimes  extending  into  the  thighs,  usually  some- 
what relieved  after  the  first  day  or  two  of  the  flow.  The  remaining  17 
cases  were  of  a  mixed  type  and  could  not  be  classed  as  either  pure  con- 
gestive or  expulsive  dysmenorrhea,  neither  one  nor  the  other  type  pre- 
dominating sufficiently  to  warrant  classifying  them  with  any  degree  of 
certainty.  In  the  majority,  however,  the  congestive  symptoms  were 
the  most  marked,  the  congestive  type  in  the  characteristic  variety  of 
dysmenorrhea  resulting  from  tuberculosis.  Simple  dilatation  or  split- 
ting of  the  cervix  is  a  failure  in  this  type  of  case,  as  there  is  no  stenosis 
of  the  canal,  and,  therefore,  no  indication  for  such  an  operation. 

Of  our  70  cases  of  dysmenorrhea,  58  were  under  35  years  of  age. 
As  already  stated,  the  characteristic  type  of  tuberculous  dysmenorrhea 
is  the  congestive  type,  and  occurred  with  sufficient  severity  to  constitute 
a  definite  symptom  in  one-fourth  of  all  our  cases.  In  not  a  few  of  our 
cases,  dysmenorrhea  has  been  the  symptom  of  which  the  patient  com- 
plained more  than  any  other.  In  one  patient  it  was  so  severe  that  on 
one  occasion  she  attempted  self-destruction.  In  48  per  cent  of  our 
cases,  the  dysmenorrhea  appeared  early  in  the  course  of  the  tubercu- 
losis, in  this  confirming  the  findings  of  Macht,1  who  observed  45.8  per 
cent  of  his  cases  of  tuberculous  dysmenorrhea  develop  during  the  first 
stage  of  the  disease.     Hollos  and  Eisenstein  13  found  dysmenorrhea  an 


290        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

early  symptom  in  tuberculosis.  They  point  out  the  frequency  with 
which  it  is  present  and  urge  a  physical  examination  of  the  chest  in  all 
patients  suffering  from  this  symptom. 

In  nearly  half  (48  per  cent)  of  our  cases  the  dysmenorrhea  ap- 
peared early  in  the  course  of  the  disease,  and  is,  therefore,  a  sign  of 
some  diagnostic  importance,  and  should  suggest  the  possibility  of  tuber- 
culosis being  present  in  all  patients  suffering  from  dysmenorrhea.  This 
is  a  point  which  should  be  emphasized.  In  not  a  few  cases  dysmenor- 
rhea is  the  chief  symptom  and  will  be  the  one  from  which  the  patient 
will  seek  relief.  If  an  examination  of  the  chest  is  not  made  and  only 
the  ordinary  treatment  for  dysmenorrhea  instituted,  not  only  will  the 
latter  be  unaffected,  but  the  lung  lesion  may  be  given  time  to  advance, 
and,  if  a  dilatation  under  ether  is  performed,  the  latter  may  be  the 
means  of  causing  an  exacerbation  of  the  pulmonary  condition. 

Expulsive  Dysmenorrhea. — All  tuberculous  patients  suffering  from 
dysmenorrhea  must  be  studied  individually.  When  found  suffering  se- 
verely from  a  definite  obstructive  type  of  dysmenorrhea,  in  some  instances 
a  dilatation  operation  may  be  performed.  Operative  relief  should,  how- 
ever, be  withheld,  unless  the  dysmenorrhea  is  of  an  unusually  severe  type 
and  the  pulmonary  lesion  mild.  In  other  words,  these  cases  are  to  be 
treated  as  any  other  surgical  case,  complicated  by  a  pulmonary  tubercu- 
losis. Dysmenorrhea  is  never  a  fatal  symptom,  whereas  operative  inter- 
vention may  be  the  means  of  lighting  up  the  pulmonary  condition.  This 
type  of  dysmenorrhea  is  not  of  tuberculous  origin  and  occurs  merely 
incidentally  in  tuberculous  subjects. 

Congestive  Dysmenorrhea. — A  more  or  less  pure  congestive  type 
is  common,  and  is  frequently  of  sufficient  severity  to  require  treatment. 
Our  experience  at  the  Henry  Phipps  Institute  in  Philadelphia  has  shown 
that  in  general  the  severity  of  the  dysmenorrhea  waxes  and  wanes  with 
the  exacerbations  or  improvement  of  the  pulmonary  condition.  If  it  is 
possible  to  build  up  the  patient's  general  condition,  so  that  she  will  show 
steady  gain  in  weight,  increased  hemoglobin,  etc.,  the  dysmenorrhea  be- 
comes less  marked,  whereas  in  the  presence  of  an  active  pulmonary  lesion 
and  the  patient  generally  going  down  hill,  the  dysmenorrhea  is  likely  to 
become  worse. 

Treatment. — The  treatment  of  these  patients  should  be  along  the 
lines  of  the  treatment  instituted  for  the  tuberculous.  Because  the  dys- 
menorrhea is  prone  to  develop  early  in  the  course  of  the  tuberculosis,  and 
may  in  some  cases  be  temporarily  the  dominant  symptom,  and  because 
of  the  general  tendency  of  surgeons  and  others  to  perform  dilatative 
operations  on  all  cases  of  dysmenorrhea,  regardless  of  their  origin  or 


MENSTRUAL    DISTURBANCES  291 

type,  it  is  of  the  utmost  importance  that  tuberculosis  be  excluded  before 
any  operative  measures  are  attempted.  Eisenstein  and  Hollas  13  report 
that  among  70  cases  of  dysmenorrhea,  in  23  tuberculosis  was  demon- 
strated. Grafenberg  7  reports  that  at  the  Kiel  Clinic  all  cases  of  dys- 
menorrhea are  examined  for  tuberculosis,  and  not  only  is  a  physical  ex- 
amination performed,  but  the  tuberculin  test  is  also  employed.  Of  30 
patients  tested  by  the  latter  means  21  reacted  with  fever,  and  all  gave 
a  general  reaction  attended  with  local  exacerbations  of  the  trouble  for 
which  they  applied  to  the  clinic.  Grafenberg  states  that,  should  the  test 
be  followed  by  a  general  and  local  reaction,  no  operative  intervention 
should  be  attempted,  and  quotes  Prochownik's  warning  against  curettage 
in  cases  of  genital  tuberculosis.  He  states  that  where  there  is  no  local 
reaction  to  the  tuberculin  test,  operation  may  be  safely  employed. 

Operation  offers  little  hope  of  relief  in  the  congestive  type  of  dys- 
menorrhea, regardless  of  its  primary  origin,  and  in  the  tuberculous  cannot 
by  any  means  be  regarded  as  free  from  danger.  Grafenberg  calls  at- 
tention to  the  frequency  with  which  tuberculous  patients  in  poor  general 
condition  suffer  from  dysmenorrhea.  Eisenstein  and  Hollas  13  found  a 
positive  tuberculous  skin  reaction  present  in  a  large  series  of  women 
suffering  from  menstrual  disturbances.  The  latter  observers  report  that 
in  22  cases  of  dysmenorrhea  treated  with  tuberculin  by  the  Spengler 
method,  16  were  cured.  The  results  in  amenorrhea  were  reported  as  even 
more  satisfactory. 

The  author's  experience  with  tuberculin  has  been  too  limited  to  draw- 
conclusions  from  it.  In  the  great  majority  of  cases,  if  the  general  health 
can  be  improved,  the  dysmenorrhea  will  improve.  During  the  carrying 
out  of  the  general  hygienic  and  dietary  'treatment,  these  patients  should 
have  special  treatment  during  the  menstrual  and  pre-menstrual  periods. 
At  these  times  the  patient  should  be  confined  to  bed,  or  at  least  to  a 
reclining  chair.  One  or  two  purgations,  accomplished  either  by  Epsom 
salts  or  castor  oil,  are  often  of  benefit  in  relieving  the  dysmenorrhea. 
These  should  be  given  so  that  they  will  act  during  the  height  of  the  pain. 
A  warm  soapsuds  enema  administered  at  this  time  is  also  of  benefit.  Hot 
applications  to  the  lower  abdomen  also  relieve  pain.  In  severe  cases  small 
doses  of  phenacetin  may  be  tried.  Opium  or  its  derivatives  should  be 
avoided,  except  under  very  exceptional  circumstances. 

Scanty  Menstruation. — Scanty  menstruation  was  found  to  be  present 
in  53  per  cent  of  our  series  of  cases.  Friedrich  14  observed  scanty  men- 
struation, or  complete  amenorrhea,  in  65  per  cent  of  a  series  of  200 
tuberculous  women.  In  tuberculous  patients  with  hypo-plastic  uteri  the 
flow  is  scanty  from  the  onset  of  menstruation  and  manifests  itself  by  a 


292        GYNECOLOGICAL  AXD  OBSTETRICAL  TUBERCULOSIS 

short  period  and  scanty  flow.  The  first  6  or  8  months  after  the  beginning 
of  menstruation,  the  periods  are  frequently  delayed,  the  individual  often 
menstruating  but  three  or  four  times  in  the  6  or  8  months  after  the  first 
menstrual  period.  The  age  of  onset  of  menstruation  in  these  patients  is 
often  somewhat  later  than  normal.  Galop  15  found  that  menstruation 
was  established  late  and  that  a  premature  menopause  frequently  occurred. 

The  tendency  for  scanty  flow  is  very  marked  in  pulmonary  tubercu- 
losis. Sometimes  this  manifests  itself  by  scanty  flow,  by  short  periods, 
by  delayed  periods,  and  even,  in  exceptional  cases,  by  complete  amen- 
orrhea. Frequently  the  scanty  flow  is  preceded  for  a  few  months  by 
menorrhagia.  Scanty  flow  is  not  only  common  in  those  cases  in  which 
there  is  hypoplasia  of  the  uterus,  but  in  those  cases  in  which  the  uterus 
is  normal  the  flow  usually  is  scant,  if  the  pulmonary  disease  is  active, 
and  especially  so  if  the  general  condition  is  poor. 

Scanty  menstruation  is  in  itself  a  symptom  which  rarely  causes  the 
patient  much  concern.  It  may  be  considered  an  effort  on  the  part  of 
nature  to  conserve  blood  and  thus  maintain  the  strength  and  resistant 
powers  of  the  patient.  Unfortunately,  scanty  menstruation  is  usually 
accompanied  by  dysmenorrhea,  sometimes  of  a  severe  type,  and  for  this 
reason  the  patients  require  treatment.  Dysmenorrhea  was  an  accompani- 
ment of  scanty  menstruation  in  88  per  cent  of  our  series.  Macht,1  who 
apparently  classifies  scanty  menstruation  under  amenorrhea,  found  that  a 
large  proportion  of  those  cases  occurred  in  young  women.  Macht's  table 
is  as  follows : 

Under  20  years  of  age 32.5  per  cent 

20  to  30    39.0 

30  to  40    23.9 

Above  40 .  .  4.6 

Macht  gives  the  following  table  showing  the  stage  of  the  pulmonary 
lesion : 

1st  stage 45.0  per  cent  of  42  patients 

2d. stage    14.0 

3d  stage    23.7 

Patients  reported  dead  at  time 

of  computing  statistics.  .  16.5 

Friedrich,14  in  the  series  of  200  patients  studied,  found  scanty  men- 
struation or  complete  amenorrhea  in  the  following  proportion  of  cases : 


MENSTRUAL    DISTURBANCES  293 

1st  stage    45  per  cent  of  42  patients 

2d  stage 64  90 

3d  stage 85  "  68 

This  report,  while  emphasizing  the  fact  that  scanty  menstruation  is  com- 
mon in  the  early  stages  of  tuberculosis,  also  shows  that,  as  the  disease 
advances,  the  menstrual  disturbances  become  more  frequent.  This  is  in 
accord  with  the  author's  observations. 

Treatment. — Scanty  menstruation  in  itself  requires  no  treatment. 
If  the  general  health  of  the  patient  can  be  improved,  the  flow  usually  be- 
comes more  normal.  Corpus  luteum  extract  is  of  value  in  some  cases. 
The  trial  of  extract  should  be  begun  about  15  or  20  days  before  an  ex- 
pected period,  administering  5  grains  3  times  a  day  and  increasing  1  pill 
daily  until  20  or  30  grains  are  taken  in  24  hours.  If  organotherapy  is 
to  be  of  value,  it  proves  itself  so  in  the  one  treatment.  If  no  benefits 
are  derived,  it  is  generally  useless  to  repeat  it.  If  the  period  is  increased 
or  the  dysmenorrhea  relieved,  it  may  be  repeated  each  month.  Of  chief 
importance  is  treatment  directed  along  the  lines  of  improving  the  general 
health. 

Irregular  Scanty  Flow. — This  was  present  in  ten  per  cent  of  our 
cases.  In  the  advanced  stages  of  pulmonary  tuberculosis  it  is  a  frequent 
symptom,  but  may  occur  early. 

Amenorrhea. — Complete  absence  of  menstruation,  either  of  the  pri- 
mary or  secondary  type,  was  present  in  5  per  cent  of  our  series.  Fried- 
rich  14  believes  it  a  common  symptom  of  pulmonary  tuberculosis.  This 
symptom  frequently  causes  mental  distress  to  the  patient.  In  many 
cases  all  the  subjective  phenomena  of  menstruation  are  present,  except 
bleeding.  The  secondary  type  frequently  gives  a  history  of  scanty  or 
irregular  bleeding  for  a  time  preceding  the  complete  cessation  of  the 
flow.  This  is  a  not  infrequent  symptom  in  advanced  cases  of  pulmonary 
tuberculosis. 

Treatment. — This  should  be  directed  towards  the  improvement  of 
the  general  condition.  Corpus  luteum  extract  is  occasionally  of  value  in 
the  treatment  of  these  cases.  In  the  married  woman  pregnancy  must  be 
excluded.  It  must  also  be  remembered  in  this  connection,  as  well  as  with 
scanty  flow,,  that  the  menopause  occurs  somewhat  earlier  in  tuberculous 
than  in  non-tuberculous  patients.  In  a  series  of  21  patients  in  various 
stages  of  pulmonary  tuberculosis,  studied  by  the  writer,  the  average  age 
of  the  onset  of  the  menopause  was  found  to  be  41  years.  The  average 
in  non-tuberculous  patients  is  about  47  years  (Norris  18). 

Menorrhagia. — Menorrhagia  was  present  in  8  per  cent  of  our  series 


294        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

of  cases.  It  is  prone  to  occur  in  conjunction  with  those  cases  in  which 
there  is  an  irregular  periodicity  of  flow.  It  rarely  persists  for  prolonged 
periods,  and  frequently  is  followed  after  a  few  months  by  scanty  flow, 
which  persists.  In  some  of  our  cases  excessive  flow  was  accompanied  by 
marked  dysmenorrhea. 

Menorrhagia  rarely  occurs  after  30  or  35  years  of  age,  unless  associ- 
ated with  a  local  lesion.  It  is  not  infrequently  an  early  symptom  of 
tuberculosis.  This  symptom  was  commented  upon  by  Hand  forth  17  as 
early  as  1887. 

Treatment. — Like  other  menstrual  disturbances  the  results  of  tuber- 
culosis, the  treatment  should  be  directed  towards  the  pulmonary  condition, 
and  if  this  can  be  improved,  the  menstrual  disturbances  usually  become 
normal.  If,  as  in  some  of  our  cases,  the  flow  is  excessive,  the  patient 
should  be  kept  in  bed  during  the  bleeding,  and  ergot  or  pituitrin  admin- 
istered. Rest  in  bed  is  usually  sufficient  to  control  the  bleeding.  Exces- 
sive flow  is  to  be  combated  more  vigorously  in  the  tuberculous  than  in 
the  non-tuberculous,  on  account  of  the  necessity  for  conserving  the 
strength  and  resistant  powers  of  the  patient. 

If  it  is  evident  that  the  flow  should  be  checked,  this  can  be  done  by 
radiumization,  small  doses  being  employed  so  as  to  avoid  the  permanent 
menopause.  By  carefully  graduated  doses  amenorrhea  can  be  produced 
for  a  few  months,  and  when  the  flow  is  reestablished,  it  is  often  normal 
in  amount.  Guillermin  18  recommends  permanent  sterilization  and  the 
production  of  the  menopause  by  the  roentgen  rays  in  some  cases. 
Whereas  sterilization  may  be  advisable  in  some  cases,  the  production  of 
the  artificial  menopause  has  definite  disadvantages,  and  should  be  em- 
ployed only  in  carefully  selected  cases. 

Vicarious  Menstruation. — In  our  series  of  214  cases  vicarious  men- 
struation was  present  in  1  patient.  This  case  was  moderately  typical. 
Macht x  believes  it  more  common  than  generally  thought  and  observed  1 5 
cases  in  her  series.  In  our  case  menstruation  was  normal  until  22  years 
of  age.  Tuberculosis  became  manifest  at  20  years  of  age.  The  patient 
was  in  the  first  stage  of  the  disease,  which  was,  when  first  seen,  quiescent, 
although  the  history  indicated  periods  of  mild  activity.  The  patient  was 
in  moderately  good  physical  condition,  and  there  was  no  other,  demon- 
strable cause  for  the  menstrual  phenomena,  the  genital  tract  being  appar- 
ently normal.  At  22  years  of  age  and  in  the  second  year  of  her 
tuberculosis,  the  menstrual  periods  became  somewhat  more  profuse  than 
formerly.  This  continued  irregularly,  one  or  two  periods  being  profuse 
and  another  scant  for  six  months.  Then  the  periods  became  very  scant 
and  lasted  only  one  day.    At  time  for  the  flow,  there  was  a  hemorrhage 


MENSTRUAL    DISTURBANCES  295 

from  the  bowel  sufficient  to  necessitate  wearing  a  pad,  the  blood  being 
bright  red  and  the  bleeding  painless.  There  was  still  a  show  of  blood 
per  vaginam  for  the  first  day.  The  bleeding  per  rectum  continued  in- 
termittently for  two  or  three  days.  The  usual  menstrual  molimina, 
tingling  in  the  breast,  etc.,  continued.  Proctoscopic  examination  showed 
the  rectum  normal.  The  periodic  bleeding  from  the  bowel  continued 
for  six  months  and  then  ceased. 

Periodic  hemoptysis  in  tuberculous  patients  has  been  frequently  ob- 
served, not  only  in  women,  but  also  in  men.  Huguenin,19  Macht,1  and 
others  record  the  histories  of  cases  in  which  hemorrhages  have  occurred 
more  or  less  regularly  at  varying  intervals.  In  considering  vicarious 
menstruation,  it  is  important,  however,  to  exclude  all  accidental  or  coin- 
cident hemorrhages.  It  is  probable  that  many  cases  of  supposed  vicarious 
menstruation  are  incorrectly  diagnosed.  Macht x  states  that  periodic 
hemorrhages  at  the  menstrual  periods  have  been  recorded  by  Tiedman,20 
Scherer,21  Kober,22  Davis,23  Flesch,24  Ford,25  Schlippe,26  Mosig  and 
Stern,27  and  others.  In  our  case  the  bleeding  was  slight ;  it  may,  however, 
be  profuse.  Macht 1  records  a  case  of  Dr.  Brown's,  in  which  the  patient 
bled  to  death,  despite  the  fact  that  there  was  improvement  in  the  pul- 
monary condition.     Flesch's  case  also  terminated  fatally. 

Vicarious  menstruation  may  occur  from  any  mucous  membrane. 
Hemorrhages  from  the  nose,  throat,  lungs,  alimentary  tract,  kidney, 
breast,  lips,  have  been  observed  by  Hauptman  2S  and  Ventura.29  Macht 30 
records  the  history  of  a  case  which  bled  regularly  from  an  ulcer  in  the 
breast. 

Treatment. — This  is  similar  to  that  indicated  for  amenorrhea  and 
scanty  menstruation.  If  the  amount  of  flow  per  vaginam  can  be  brought 
up  to  the  normal,  the  vicarious  bleeding  usually  ceases. 

Leukorrhea. — Gallard  31  has  referred  to  the  occurrence  of  periodic 
leukorrhea.  Leukorrhea  in  general  is  usually  more  profuse  just  before 
and  after  menstruation.  Our  investigations  have  not  shown  that  leuk- 
orrhea is  either  more  frequent  or  profuse  in  the  tuberculous  than  in  the 
non-tuberculous.  No  periodic  leukorrhea  other  than  the  type  above 
mentioned  has  been  observed. 

The  Influence  of  Menstruation  on  the  Temperature  in  Pul- 
monary Tuberculosis. — As  early  as  1878,  Goodman,32  and  later  von 
Ott 33  and  others  have  demonstrated  that  definite  changes  occur  in  the 
woman  at  the  menstrual  period.  These  changes  are  not  only  local,  but 
affect  more  or  less  the  entire  economy.  Goodman,  von  Ott,  and  others 
believe  that  among  other  changes  for  a  few  days  prior  to  the  appearance 
of  the  menstrual  flow  there  is  a  slight  rise  in  temperature,  in  pulse  rate, 


296        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

respiration,  and  the  entire  nervous  system  is  somewhat  more  sensitive 
at  this  time.  When  the  flow  becomes  established,  all  these  conditions 
suddenly  drop  to  a  point  somewhat  below  the  normal  line,  from  which 
time  there  is  a  gradual  rise  until  the  next  menstrual  period.  An  increase 
in  temperature  is,  however,  seen  in  many  cases  apparently  normal. 

In  considering  the  rise  of  temperature  which  often  occurs  at  the  men- 
strual period  in  pulmonary  tuberculosis,  the  so-called  Goodman-von  Ott 
wave  must  be  taken  into  consideration.  From  the  observations  of  others, 
and  from  our  own  studies,  however,  it  seems  established  that  in  the  tuber- 
culous the  tendency  towards  a  rise  in  temperature  is  considerably  above 
that  present  in  the  normal  woman.  This  rise  in  temperature  is  of  distinct 
diagnostic  importance.  According  to  Kraus,34  it  occurs  in  66  per  cent  of 
cases.  Weisse  35  observed  a  premenstrual  rise  in  40  per  cent  of  cases. 
Only  32  per  cent  had  normal  temperature  during  menstruation.  Han- 
sen 36  observed  a  premenstrual  or  menstrual  rise  in  temperature  in  the 
majority  of  cases.  The  increase  in  temperature  is  thought  to  be  due  to 
a  certain  degree  of  exacerbation  of  the  pulmonary  condition,  which  is 
explained  by  a  hyperpyrexia  of  the  lungs.  Macht x  states  that  at  the 
menstrual  period  all  symptoms  exhibit  a  tendency  to  become  worse. 
Cough,  expectoration,  anorexia,  general  malaise,  etc.,  become  more  mani- 
fest, while  laryngeal  involvement  is  prone  to  spread  and  physical  signs 
become  more  marked.  The  exacerbation  is  usually  transient,  but  may 
continue.  Taking  a  basis  of  99°F.  as  the  standard,  Weisse35  found  that 
13  per  cent  of  patients  had  a  menstrual  rise  of  temperature  usually  on 
the  first  day  of  flow,  at  times  continuing  over  the  second;  (10  per  cent 
in  the  first  stage  of  tuberculosis,  15  per  cent  in  the  second  stage,  and  17 
per  cent  in  the  third  stage).  Weisse's  statistics  were  formulated  from 
a  series  of  500  cases  of  active  pulmonary  tuberculosis,  Riebold  37  found 
a  rise  in  12  per  cent  of  cases.  Sabourin  38  found  the  rise  in  temperature 
a  frequent  symptom.  Scherer  21  observed  a  rise  most  frequently  in  ad- 
vanced cases.  Noncher,39  whose  paper  contains  a  valuable  bibliography, 
found  a  rise  in  temperature  in  either  the  premenstrual  or  menstrual  pe- 
riods in  50  per  cent  of  cases,  Kraus  34  in  66  per  cent,  Macht x  in  40 
per  cent.  Van  Voornveldt  40  has  recorded  a  case  in  which  there  was  a 
regular  intermenstrual  rise  which  may  be  somewhat  analogous  to  the 
mid  scJimcrchcn  occasionally  observed.  As  seen  from  the  above 
figures,  the  premenstrual  rise  is  the  most  frequent.  Postmenstrual  rise 
of  temperature  was  observed  in  but  24  per  cent  of  cases  and  is  an 
unfavorable  sign. 

This  rise  in  temperature  may  occur  in  otherwise  normal,  or  may 
manifest  itself  as  a  higher  rise  in  temperature  at  the  menstrual  period  in 


MENSTRUAL    DISTURBANCES  297 

those  patients  who  are  experiencing  more  or  less  fever.  The  fever  is 
generally  highest  in  the  evening. 

The  rise  in  temperature  may  be  present  in  mild  as  well  as  in  advanced 
cases.  Geisler's  41  suspicion  was  in  one  case  first  aroused  towards  an 
incipient  lung  lesion  by  these  symptoms.  A  marked  rise  in  temperature 
is  usually  an  indication  of  an  active  lesion,  and  is  an  unfavorable  prog- 
nostic sign.  So  frequent  is  a  slight  rise  in  temperature,  that  this  symp- 
tom should  warn  of  possible  presence  of  pulmonary  tuberculosis  and  calls 
for  an  examination.  A  previously  silent  case  may  give  positive  findings 
at  or  just  before  the  menstrual  period.  The  rise  in  temperature  at  the 
menstrual  period  in  tuberculous  women  has  been  the  subject  of  consid- 
erable study,  papers  having  been  devoted  to  it  by  Mantoux,42  Riebold,37 
Sabourin,38  Kraus,34  Scherer,21  Pel,43  and  others. 

Pregnancy,  even  in  the  early  stages,  not  infrequently  exerts  an  un- 
favorable influence  on  the  course  of  pulmonary  tuberculosis.  When  it 
is  considered  how  closely  the  early  stage  of  pregnancy  resembles  the 
physiologic  process  incident  to  menstruation,  the  etiologic  relationship 
of  the  exacerbation  which  sometimes  occurs  at  the  menstrual  periods  can 
be  readily  understood.  Menstruation  may  be  viewed  as  a  preparation  of 
the  genital  tract  for  the  implantation  in  the  uterus  of  the  fertilized  ovum. 
The  same  congestion  of  the  genital  tract,  the  thickening  of  the  endome- 
trium, the  nervous  phenomena,  are  common  to  both  conditions  and  are 
the  same  as  occur  in  pregnancy,  but  to  a  lessened  degree.  Menstruation 
has  been  well  termed  the  abortion  of  the  unfertilized  ovum. 

From  a  practical  viewpoint,  the  fact  that  at  the  menstrual  period 
pulmonary  tuberculosis  is  especially  prone  to  exhibit  exacerbations  calls 
for  especial  care  of  all  patients  at  this  time.  Rest  in  bed,  or  at  least 
the  reducing  of  all  physical  exertion,  is  of  prime  importance  at  this 
time.  If  dysmenorrhea  or  other  menstrual  disturbances  are  present,  rest 
will  serve  a  double  purpose. 

All  factors  which  are  prone  to  exert  an  unfavorable  influence  on  the 
pulmonary  lesions  should  be  avoided  as  much  as  possible.  Thus,  especial 
care  should  be  exercised  against  "taking  cold."  Overheating  should  be 
avoided  and  the  diet  and  bowels  should  be  carefully  regulated.  These 
precautions  should  be  instituted  for  a  few  days  prior  to,  and  for  the  first 
few  days  of,  the  flow.  Such  precautions  are  indicated  in  all  patients 
suffering  from  pulmonary  tuberculosis,  but  are  especially  called  for  in 
those  patients  who  exhibit  a  rise  in  temperature  at,  or  prior  to,  the  men- 
strual periods.  Macht 1  and  other  authorities  warn  against  the  adminis- 
tration of  tuberculin  at  this  time.  Owing  to  the  tendency  toward  exacer- 
bations of  the  pulmonary  lesions  at  this  time,  operative  intervention  of 


298        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

all  kinds  should  be  avoided.  This  applies  to  cases  of  frank  pulmonary, 
tuberculosis,  and  also  to  suspected  or  incipient  ones,  thus  including  all 
tuberculous  lesions  of  the  genital  tract,  which  are,  in  the  majority  of  in- 
stances, secondary  to  pulmonary  tuberculosis. 


LITERATURE 

Macht,  D.  I.    Am.  Jr.  Med.  Sc.     1910.     140:835. 

Thorn.    Centrbl,  f.  Gebh.  u.  Gyn.    16:67. 

Butner,  A.  J.    111.  Med.  Jr.     1915.    27:92. 

DeJong,  L.    These  de  Paris.     1914. 

Poucet  et  Leriche.    La  gyn.    May,  1910. 

Sessa,  P.    La  ped.     1914.    22  :255. 

Grafenberg,  E.    Munch.  Med.  Woch.     1910.    p.  515. 

Schiffman.    Arch.  f.  Gyn.     1914.   103. 

Merlitti.    Arch,  di  ost.  e  gin.    1901.    p.  612,  649,  714. 

de  Rouville,  M.     Bui.  soc.  d'obst.  et  de  gyn.  de  Paris.     1914 

P-  559- 
Tobler,  M.    Monschr.  f.  Gebh.  u.  Gyn.     1905.     22 :  No.  1. 
Schaffer.    In  Veit's  Handbuch. 
Hollas,  J.,  und  Eisenstein,  K.    Gyn.  rundsch.     1907.     No.  23. 

Also,  Ztschr.  f.  Gyn.     1908.     No.  44. 
Friedrich,  M.    Arch.  f.  Gyn.     1913.     101 1376. 
Galop,  M.  J.     La  gyn.      1913.      17:659. 
Norris,  C.  C.    Am.  Jr.  Obst.     1919. 
Handforth.    Brit.  Med.  Jr.     1887.    p.  153. 
Guillermin,  R.    Rev.  med.  de  la  Suisse  rom.     1919.    38:  No.  7. 
Huguenin.     Lungebluthunger.     Cor-bl.   f.   Schw.  artzte.     1898. 

38  -97 '■ 
Tiedman.     Inaug.  Dis.     Wurtzberg,  1842. 
Scherer.    Brauer's  Beitr.    6 :287. 
Kober.    Berl.  Klin.  Woch.     1895.    No.  2. 
Davis.    Lancet.     1884.     11:782. 
Flesch.     Centrbl.  f.  Gyn.     1890.     No.  37. 
Ford.    Am.  Jr.  Obst.     1899.    p.  154. 
Schlippe.    Brauer's  Beitr.    8  Y2jj. 
Mosig  et  Stern.    Rev.  de  la  tuberc.    Oct.,  1907. 
Hauptman.    Munch.  Med.  Woch.    Oct.  29,  1909. 
Ventura,  C.    Gac.  d.  osp.    1907.    No.  129. 
Macht,  D.  I.    N.  Y.  Med.  Rec.    Feb.  29,  1910. 


MENSTRUAL    DISTURBANCES  299 

31.  Gallard.    Ztscht.  f.  Gyn.    1886.    p.  561. 

32.  Goodman.    Am.  Jr.  Obst.     1878. 

33.  von  Ott.    Intnat.  Kong.    Berlin,  1890. 

34.  Kraus.    Wiess.  Med.  Woch.     1905.    No.  13. 

35.  WeIsse,  F.  W.     Beitr.  z.  Klin.  d.  Tuberk.     1913.     4:335. 

36.  Hansen,  B.    Beitr.  z.  Klin.  d.  Tuberk.     1913.    27:291. 

37.  Riebold.     Beitr.  z.  Klin.  d.  Tuberk.     1899.     19:8. 

38.  Sabourin.    Rev.  de  med.     1905.    p.  275. 

39.  Noncher.     These  de  Paris.     1906. 

40.  Van  Voornvedlt.    Ztschr.  f.  Tuberk.     1905.    p.  543. 

41.  Geisler.    Russky  oratch.     1909.     No.  3. 

42.  Mantoux.    Rev.  de  la  tuberc.    Oct.,  1905. 

43.  Pel,  P.  K.    Berl.  Klin.  Woch.    1909.    No.  38. 


CHAPTER  XIII 

PULMONARY  TUBERCULOSIS  AND  OPERATION 

Three  distinct  dangers — Choice  of  anesthetic — Classification  of  pulmonary  tubercu- 
losis based  on  physical  findings  and  constitutional  symptoms — Subdivision  into 
groups — Study  of  different  stages  of  the  disease — Spinal  anesthesia — Precautions 
before  operation — Importance  of  expert  anesthetist — Convalescence — Results — 
Condition  of  pulmonary  lesion  six  or  more  months  after  operation  performed 
under   general    anesthetic — Statistical    report — Bibliography. 


CLASSIFICATIONS 

Pulmonary  tuberculosis  is  one  of  the  most  frequent  diseases  to  which 
mankind  is  heir.  When  it  becomes  necessary  to  subject  a  patient  suffering 
from  this  form  of  infection  to  operation,  the  individual  so  treated  is 
exposed  to  materially  greater  risk  than  is  the  non-tuberculous  patient. 
Three  distinct  dangers  occur,  which  are  not  present  in  the  non-tuberculous 
patient :  ( i )  the  operation  itself  may  be  the  means  of  disseminating  the 
infection  either  to  distant  and  hitherto  uninfected  parts  of  the  body,  or 
it  may  result  in  an  exacerbation  of  the  pulmonary  process;  (2)  if  a 
general  anesthetic  is  employed,  this  may  light  up  the  pulmonary  lesion; 
and  (3)  to  these  dangers  are  added  the  fact  that  the  tuberculous  patient 
is  generally  below  par,  and  possesses  lessened  resistant  powers,  and  is 
therefore  less  able  to  withstand  the  dangers  common  to  operation.  When 
a  general  anesthetic  has  been  employed  and  ill  results  follow,  it  is  some- 
times difficult  to  determine  whether  these  are  the  results  of  the  anesthetic 
or  the  operation. 

From  a  practical  standpoint,  however,  it  is  safe  to  assume  that  all 
tuberculous  patients  are  less  favorable  operative  risks,  and  operations 
upon  them  are  followed  by  greater  morbidity  and  a  higher  mortality 
than  in  non-tuberculous  patients.  As  the  risks  are  greater,  the  indications 
for  operation  should  be  well  denned.  In  considering  the  subject,  it  is 
necessary  to  individualize  all  patients.  Naturally,  the  graver  the  pulmon- 
ary lesion,  the  greater  are  the  dangers  incident  to  operation,  and  the 
more  urgent  should  be  the  necessity  for  operation,  before  such  is  advised. 
Thus,  in  mild  quiescent  pulmonary  lesions,  operations  may  be  advised  to 

300 


PULMONARY  TUBERCULOSIS  AND  OPERATION  301 

do  away  with  some  discomfort  which  would  never  threaten  the  life  of 
the  patient,  such,  for  instance,  as  a  laceration  of  the  peritoneum  which  is 
producing  definite  symptoms ;  on  the  other  hand,  operation  would  never 
be  justifiable  for  a  similar  gynecological  lesion  in  a  patient  the  incumbent 
of  an  advanced  or  active  pulmonary  tuberculosis.  In  the  case  of  an 
operable  cancer,  however,  great  risks  are  justifiable,  as  it  is  known  that 
the  patient  is  doomed  if  the  tumor  is  not  removed,  whereas  the  pulmon- 
ary lesion,  even  if  advanced,  may  possibly  be  checked  and  held  in  abeyance 
for  years,  or  even  cured. 

Various  classifications  of  pulmonary  tuberculosis  have  been  suggested; 
one  of  the  most  satisfactory  is  that  of  the  American  Medical  Association, 
which  depends  upon  a  combination  of  the  physical  finding  and  the  con- 
stitutional symptoms.  This  classification  divides  pulmonary  tuberculosis 
into  three  stages. 

In  Stage  I  are  placed  all  incipient  cases  and  those  which  present  slight 
or  no  constitutional  symptoms.  The  temperature  is  not  over  100.50  F., 
pulse  under  90,  expectoration  not  more  than  30  c.c.  in  the  twenty-four 
hours.  Physical  signs  limited  to  infiltration  above  the  clavicles,  if 
bilateral,  or  to  above  the  second  rib,  if  unilateral. 

Stage  II  comprises  the  moderately  advanced  cases.  In  this  stage 
there  are  no  marked  local  or  constitutional  symptoms.  Marked  dyspnea, 
extreme  weakness,  anorexia,  tachycardia,  are  constitutional  symptoms 
excluding  the  patient  from  this  class.  Physical  examination  must  show 
that,  if  unilateral,  not  more  than  half  of  one  lobe  is  involved;  if  bilateral, 
involvement  even  less,  and  there  must  be  only  slight  or  no  evidence  of 
cavity  formation. 

Stage  III  includes  far  advanced  cases,  all  those  in  which  there  are 
marked  constitutional  symptoms,  and  all  those  in  which  the  physical 
examination  shows  consolidation  of  more  than  one  lobe  of  the  lung;  if 
unilateral,  advanced  cavity  formation,  or  all  those  cases  which  are 
advanced  beyond  Class  II.  Miliary  tuberculosis  is  classified  separately. 
It  has  been  our  experience  that  physical  signs  generally  rather  under- 
estimate the  extent  of  the  pulmonary  lesion,  and  this  is  in  accord  with 
the  statement  of  Brown.1 

First  Stage. — In  our  work  we  have  subdivided  this  class  of  cases  into 
two  groups.  The  first  (group  A)  comprises  those  cases  which  are  prac- 
tically free  from  subjective  symptoms,  and  the  only  indication  of  a 
pulmonary  lesion  is  that  there  are  present  slight  physical  signs  and  a 
suggestive  history.  To  this  group  is  added  all  cases  of  tuberculosis  of 
the  genital  tract  which  present  no  evidence  of  pulmonary  lesions  beyond 
the  fact  that  we  know  nearly  all  genital  lesions  are  secondary  and  that, 


302        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

where  there  is  no  other  demonstrable  primary  lesion,  it  is  probable  that 
the  lungs  were  the  primary  seat.  It  is  true  that  by  treating  this  latter 
class  of  cases  as  if  they  were  the  incumbents  of  a  pulmonary  lesion  it  is 
probable  that  a  few  primary  genital  lesions  are  included.  However,  this 
is  erring  on  the  side  of  safety. 

Patients  presenting  no  subjective  symptoms  and  only  mild,  quiescent 
or  even  suspicious  physical  signs  stand  even  a  general  anesthetic  well,  and 
while  the  indication  for  operation  should  be  somewhat  greater  than  in 
those  patients  with  normal  lungs,  nevertheless  the  risk  is  so  slight  that 
it  is  unjustifiable  to  allow  these  patients  to  suffer  when  operation -offers 
a  reasonable  hope  of  cure. 

Group  B  consists  of  patients  in  Stage  I  who  are  exhibiting  symptoms 
such  as  mild  cough,  expectoration,  slight  fever,  or  a  little  acceleration  of 
pulse.  In  these  a  decidedly  more  cautious  attitude  should  be  assumed. 
In  this  class  of  cases  Brown's  warning  that  the .  physical  signs  often 
underestimate  the  pulmonary  lesions  should  be  borne  in  mind.  The 
administration  of  ether  to  such  a  patient,  while  in  the  majority  of  cases 
is  harmless,  will,  however,  in  a  certain  percentage  of  cases  be  the 
agency  which  will  light  up  the  pulmonary  lesion  or  produce  an  extension 
of  the  disease.  With  this  group  of  cases,  therefore,  when  the  surgical 
condition  permits,  it  is  preferable  to  advise  a  course  of  preliminary  treat- 
ment in  an  endeavor  to  improve  their  pulmonary  condition  so  that  it  will 
come  under  Group  A.  If  this  is  impossible  and  operation  is  demanded, 
the  patient  should  receive  a  preliminary  dose  of  morphin  gr.  ]/\  to  1/3 
with  atropin  gr.  1/150.  Local  anesthesia  is  the  anesthetic  of  choice,  and 
much  may  be  done  under  local  anesthesia,  if  a  careful  technic  is  devel- 
oped. If  the  entire  operation  cannot  be  performed  under  local  anesthesia, 
it  may  be  supplemented  with  nitrous  oxid,  which  is  decidedly  preferable 
to  ether.  If  deep  anesthesia  and  relaxation  is  necessary,  a  few  whiffs  of 
ether  may  be  employed  during  that  stage  of  the  operation  in  which  it  is 
required.  Its  use  should  be  avoided  if  possible,  and  only  enough  given 
to  obtain  the  desired  effect,  and  a  switch  back  to  nitrous  oxid  made  as 
soon  as  the  conditions  permit.  Patients  in  Group  A,  Stage  I,  are  treated 
as  if  in  Group  B,  except  that  the  operative  indications  are  less  strictly 
drawn  and  there  is  less  hesitancy  in  resorting  to  a  general  anesthetic. 

Second  Stage. — The  indications  for  operation  should  be  well  defined, 
and,  with  few  exceptions,  operative  intervention  requiring  a  general 
anesthetic  should  be  refused  to  patients  in  this  stage  of  tuberculosis,  unless 
surgical  intervention  is  demanded  as  a  life  saving  measure.  The  admin- 
istration of  a  general  anesthetic  is  extremely  hazardous,  and  ether  espe- 
cially "dangerous.     In  this  stage  of  the  pulmonary  disease  every  .effort 


PULMONARY  TUBERCULOSIS  AND  OPERATION  303 

should  be  made  to  employ  only  a  local  anesthesia.      The   preliminary 
administration  of  scopolamin  with  morphin  is  of  advantage. 

Third  Stage. — All  that  has  been  said  regarding  the  danger  of  a  gen- 
eral anesthetic  in  the  preceding  stage  is  doubly  true  in  this  group  of 
patients.  Most  of  these  patients  are  doomed  as  a  result  of  the  pulmonary 
conditions,  and  an  attempt  to  alleviate  surgical  conditions  generally  means 
hurrying  the  end. 

Choice  of  the  Anesthetic. — The  choice  of  the  anesthetic  to  be  em- 
ployed when  operating  upon  patients  suffering  from  pulmonary  tuber- 
culosis is  of  the  utmost  importance.  The  choice  naturally  will  be  deter- 
mined by  the  character  of  the  operation  necessary,  the  character  of  the 
pulmonary  lesion,  and,  to  an  appreciable  degree,  upon  the  skill  of  the 
surgeon. 

Spinal  Anesthesia. — This  form  of  anesthesia  is  sometimes  advis- 
able in  patients  in  the  second  and  third  stages.  In  the  writer's  opinion  this 
form  of  anesthesia  is  in  itself  distinctly  dangerous ;  nevertheless  cases  "in 
advanced  pulmonary  tuberculosis  which  have  to  be  operated  upon  in 
which  local  anesthesia  cannot  be  employed  are  safer  with  spinal  than 
with  a  general  anesthetic.  Some  years  ago  the  surgical  literature  was 
rife  with  enthusiastic  reports  of  this  form  of  "anesthesia,  but,  while  it  is 
still  employed  successfully  by  many  operators  who  have  probably  attained 
especial  skill  in  its  use,  its  dangers  and  ill  effects  are  now  recognized.  As 
a  matter  of  fact,  the  cases  of  advanced  pulmonary  tuberculosis  that 
demand  operation  are  few  in  number,  and  it  is  to  those  in  which  local 
anesthesia  cannot  be  employed  that  spinal  anesthesia  is  especially  valuable. 
The  writer's  experience  with  spinal  anesthesia  is  limited  to  twenty-two 
cases,  in  all  of  which  the  Gellhorn  technic  was  employed. 

Miliary  tuberculosis  is  in  itself  generally  a  rapidly  fatal  disease,  and 
surgical  treatment  is  rarely  if  ever  necessary. 

Hewitt  2  states  that  patients  with  old  lesions  stand  anesthesia  well. 
This  authority  recommends  the  use  of  the  C.  E.  mixture,  or  the  C.  E. 
chloroform  sequence,  or  open  ether,  preceded  by  the  administration  of 
atropin.  He  believes  that  nitrous  oxid  may  also  be  safely  employed  in 
chronic  cases,  but  should  not  be  pushed  so  far  as  in  the  normal.  Gwath- 
mey  and  Baskerville  3  recommend  nitrous  oxid  as  the  anesthetic  of  choice, 
and  warmed  chloroform  and  oxygen  as  their  second  choice.  They  believe 
ether  is  contra-indicated.  Magaw  4  states  that  these  patients  stand  ether 
well. 

Precautions  Before  Operation. — Presuming  that  the  diagnosis  of 
pulmonary  tuberculosis  has  been  made,  and  a  physical  examination  has 
shown  that  the  case  is  in  the  first  stage  of  the  disease,  what  precautions 


304   GYXECOLOGICAL  AXD  OBSTETRICAL  TUBERCULOSIS 

can  be  taken  to  minimize  .as  much  as  possible  the  dangers  incident  to 
surgical  intervention?  In  the  gynecological  department  of  the  University 
of  Pennsylvania  it  has  been  a  rule  that  no  tuberculous  patients  are  sub- 
jected to  operation,  who  are  running  a  temperature  of  more  than  99  °  F., 
unless  the  operation  is  very  urgently  demanded.  Thus,  in  the  case  of 
ordinary  tuberculous  salpingitis  in  a  patient  exhibiting  a  slight  evening 
rise  of  temperature,  we  believe  that  it  is  "usually  safer  to  delay  operation 
until  such  time  as  the  temperature  is  normal.  In  the  interval  this  class 
of  patients  should  receive  appropriate  hygienic  and  dietary  treatment, 
and,  if  it  is  thought  that  the  fever  may  be  caused  by  the  pelvic  .lesion, 
the  usual  palliative  treatment  for  such  conditions  is  instigated.  Usually, 
after  a  week  or  two  of  such  treatment,  the  temperature  returns  to  the 
normal  and  the  operation  may  be  performed.  With  "this  method,  and 
with  patients  in  the  first  stage  of  pulmonary  tuberculosis,  good  results 
have  been  obtained.  Occasionally  a  case  will  be  encountered  in  which 
the  fever  continues,  and  under  such  circumstances  a  further  delay  is 
usually  advisable.  A  sharp  line  must  be  drawn  even  in  patients  in  the 
first  stage  of  the  disease,  between  those  patients  in  whom  the  pulmonary 
lesions  exhibit  a  tendency  to  be  active  and  those  in  whom  they  are  non- 
active.  In  the  former  the  risks  incident  to  operation  are  definite,  whereas 
in  the  latter  it  has  been  our  experience  that  they  are  small. 

The  above  treatment  should  be  employed  in  all  cases  in  which  a 
pulmonary  lesion  is  suspected,  as,  for  example,  when  a  virginal  patient  is 
found  to  be  suffering  from  a  pelvic  inflammatory  disease,  as  the  majority 
of  such  cases  are  of  tuberculous  origin,  and,  even  when  the  history  and 
physical  signs  are  negative  for  tuberculosis,  it  is  safe  to  treat  such 
patients  as  if  they  were  the  incumbents  of  an  incipient  pulmonary  lesion. 

The  administration  of  atropin  combined  with  a  small  dose  of  morphin, 
prior  to  the  administration  of  a  general  anesthetic,  is  advisable  in  all 
cases.  The  morphin  quiets  the  patient,  and,  as  a  result,  if  a  general 
anesthetic  is  necessary,  it  is  better  taken  and  less  is  required,  and  there  is 
a  lessened  danger  of  straining,  vomiting,  etc.,  while  the  atropin  lessens 
the  secretion  of  mucus.  An  expert  anesthetist  should  be  at  hand,  if  a 
general  anesthetic  is  employed.  It  is  of  the  utmost  importance  that  these 
patients  take  the  anesthetic  quietly,  and  that  they  do  not  "fill  up"  with 
mucus  during  the  course  of  its  administration.  While  atropin  and 
morphin  are  of  distinct  value  in  attaining  these  ends,  an  expert  anesthetist 
is  of  even  greater  importance.  This  point  cannot  be  too  greatly  empha- 
sized. 

Especial  care  should  be  exerted  to  avoid  chilling  of  the  patient  while 
on  the  way  to  and  from  the  operating  room. 


PULMONARY  TUBERCULOSIS  AXD  OPERATION  305 

If  a  general  anesthetic  is  employed,  the  operation  should  be  performed 
as  quickly  as  possible,  so  that  the  patient  will  not  be  under  anesthesia 
longer  than  is  absolutely  necessary.  If  a  general  anesthetic  is  necessary, 
nitrous  oxid  is  far  preferable  to  ether.  The  author  has  had  but  little 
experience  with  chloroform  and  other  varieties  of  general  anesthetics. 
Gwathmey  and  Baskerville  3  especially  recommend  the  employment  of 
nitrous  oxid  in  tuberculous  patients.  Some  authors  recommend  that  the 
ether  fumes  be  warmed.  This  may  be  of  value,  but  has  not  been 
employed  by  us  in  our  work.  The  anesthesia  should  be  as  light  as 
possible,  only  sufficient  being  administered  to  keep  the  patient  under  its 
influence.  This  is  especially  true  if  ether  is  employed.  On  the  other 
hand,  much  harm  may  be  done  by  a  timid  or  inexperienced  anesthetist, 
who  allows  a  patient  to  come  partly  out  of  ether  during  the  performance 
of  the  operation.  This  often  means  that  the  patient  vomits  or  becomes 
"filled  up"  with  mucus,  and  always  means  that  the  total  amount  of  ether 
employed  will  be  greater  than  if  an  even  anesthesia  has  been  administered. 
At  the  completion  of  the  operation  and  before  the  patient  has  come  out 
of  the  ether,  it  is  generally  a  good  plan  to  wash  out  the  stomach,  as  this 
tends  to  prevent  postoperative  vomiting.  Vomiting  in  tuberculous 
patients  is  to  be  especially  avoided,  owing  to  the  increased  strain  put 
upon  the  lungs.  Excessive  straining  or  vomiting  may  be  the  means  of 
breaking  down  hitherto  incapsulated  pulmonary  lesions.  The  inspiration 
of  mucus  should  also  be  especially  guarded  against,  both  during  the 
administration  of  the  anesthetic  and  while  recovering  from  it.  The 
operating  room  should  be  warm  and  chilling  of  the  patient  avoided. 

Convalescence. — In  the  tuberculous  patient  this  should  be  especially 
guarded.  Particular  care  to  avoid  chilling,  exposure,  etc.,  should  be 
exerted  immediately  following  operation.  Vomiting  and  straining  should 
be  eliminated  as  much  as  possible  by  appropriate  measures.  The  admin- 
istration of  a  small  dose  of  morphin  or  codein  as  soon  as  the  patient 
begins  to  come  out  of  the  anesthesia  is  usually  advisable  and  may  be 
repeated  somewhat  more  frequently  than  with  the  non-tuberculous  patient. 
With  the  above  exceptions  the  subsequent  surgical  convalescence  differs 
in  no  respect  from  the  ordinary  case.  The  latter  treatment  is  that  usually 
indicated  for  tuberculous  patients  in  general,  and  is  especially  to  be  recom- 
mended for  all  operative  cases. 

Results. —  Doderlein  and  Kronig,5  Zweifel,8  Wahlander 7  and 
Mayer  8  have  remarked  an  exacerbation  following  surgical  intervention 
in  tuberculous  patients.  Furniss  9  suggests  that  this  reaction  is  not  due 
to  an  actual  dissemination  of  tuberculous  material,  but  that  the  condition 
is  owing  to  the  "reactivation"  of  the  tuberculous  process  by  the  tuber- 


306        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

culin  liberated  by  the  disturbance  of  the  operation.  This  reaction 
occurs  about  twelve  hours  after  the  operation,  and  is  characterized  by 
a  rise  in  temperature  of  2  to  40  F.,  an  increase  in  pulse  rate,  general 
malaise,  body  ache  and  often  headache.  A  reaction  such  as  described 
by  Furniss,  but  usually  somewhat  milder,  has  been  observed  in  many 
of  our  cases.  Again,  a  slight  reaction  is  a  certainty  in  many  operative 
cases  even  when  nontuberculous.  In  our  cases  this  reaction  has  not,  as 
a  rule,  been  greater  than  in  the  nontuberculous.  Weil 10  and  others  have 
reported  cases  of  miliary  tuberculosis  following  operation  upon  tuber- 
culous patients. 

Prochownik  "  has  carefully  examined  7  cases  in  which  tuberculosis 
apparently  followed  gynecologic  operation  and  resulted  in  death.  These 
were  simple  operations,  such  as  dilatation  and  curettage,  reposition 
retrodisplaced  uteri,  salpingectomy,  etc.  In  5  of  these  patients  there 
was  no  evidence  of  latent  tuberculosis.  Prochownik  urges  the  necessity 
of  a  thorough  examination  in  all  suspected  cases  of  pelvic  inflammation 
which  do  not  yield  in  a  reasonable  time  to  palliative  means.  As  previously 
stated,  our  experience  has  been  that  in  the  mild  cases,  and  properly  safe- 
guarded, operation  is  comparatively  safe.  Kinghorn  12  reports  a  similar 
experience.  Certainly,  however,  all  tuberculous  patients  subjected  to 
operation  are  exposed  to  definitely  greater  risks  than  the  non-tuberculous, 
and  this  must  be  taken  into  consideration  when  deciding  for  or  against 
the  advisability  of  operation.  Nearly  all  cases  of  tuberculosis  of  the 
female  genital  tract,  peritoneum,  or  intraperitoneal  organs  are  secondary, 
and,  in  the  majority  of  cases,  are  secondary  to  pulmonary  tuberculosis. 
The  pulmonary  lesions  are  frequently  latent,  but  are  nevertheless  a  source 
of  danger,  and  should  be  definitely  considered  and  safeguarded  as  far  as 
possible.  On  account  of  the  predominance  of  secondary  lesions  in  many 
cases  and  the  difficulty  often  experienced  in  demonstrating  small  quiescent 
pulmonary  lesions,  all  cases  of  genital  tuberculosis  should  be  treated  as 
if  pulmonary  involvement  were  known  to  be  present. 

The  following  are  the  results  attained  in  a  series  of  126  cases  of 
pulmonary  tuberculosis  operated  upon  under  general  anesthesia  for 
various  gynecological  conditions.  Most  of  these  patients  had  small 
quiescent  pulmonary  lesions,  and  in  a  few  they  were  of  the  unsuspected 
variety,  the  diagnosis  of  tuberculosis  having  been  made  by  histologic 
examination  of  the  specimen  removed  at  operation,  no  demonstrable 
primary  lesion  in  the  lungs  or  elsewhere  having  been  present.  All  cases 
in  which  the  end  results  have  been  studied  have  been  followed  for  at  least 
six  months  and  many  for  much  longer  periods.  In  this  series  there 
were  no  operative  deaths. 


PULMONARY  TUBERCULOSIS  AND  OPERATION 


307 


CONDITION   OF   PULMONARY  LESION    SIX    MONTHS    OR    MORE  AFTER    OPERATION     PERFORMED 
UNDER   GENERAL   ANESTHESIA 


Stage  of  Pulmonary 

Lesion  at  Time  of 

Operation 

Number  of  Cases 

Improved 

No 
Change 

Worse 

Dead 

1st  stage,  group  A 

104 

24 

76 

3 

1 

1st  stage,  group  B 

18 

3 

13 

1 

1 

II  stage 

4 

0 

3 

1 

0 

III  stage 

0 

0 

0 

0 

0 

Total 

126 

27 

92 

5 

*2 

CONDITION   OF   PULMONARY  LESION    SIX    MONTHS    OR    MORE  AFTER    OPERATION     PERFORMED 
UNDER    NITROUS   OXID    AND   OXYGEN    ANESTHESIA 


Stage  of  Pulmonary 

Lesion  at  Time  of 

Operation 

Number  of  Cases 

Improved 

No 
Change 

Worse 

Dead 

1st  stage,  group  A 

54 

15 

39 

0 

0 

1st  stage,  group  B 

10 

2 

7 

1 

0 

II  stage 

2 

0 

2 

0 

0 

III  stage 

0 

0 

0 

0 

0 

Total 

66 

17 

48 

1 

0 

CONDITION   OF   PULMONARY  LESION    SIX    MONTHS    OR    MORE  AFTER    OPERATION    PERFORMED 
UNDER   NITROUS   OXID,   OXYGEN,    AND    ETHER    ANESTHESIA 


Stage  of  Pulmonary 

Lesion  at  Time  of 

Operation 

Number  of  Cases 

Improved 

No 
Change 

Worse 

Dead 

1st  stage,  group  A 

SO 

9 

37 

3 

1 

1st  stage,  group  B 

8 

1 

6 

0 

1 

II  stage 

2 

0 

1 

1 

0 

III  stage 

0 

0 

0 

0 

0 

Total 

60 

10 

44 

4 

T2 

*One  of  these  occurred  three  months  after  operation,  and  was  due  to  an  exacer- 
bation of  the  pulmonary  condition  directly  traceable  to  the  anesthesia.  The  other 
death  occurred  in  a  case  in  which  the  tuberculous  origin  of  the  pelvic  lesion  was  only 
discovered  during  the  course  of  the  routine  histologic  examination  of  the  specimen  re- 
moved at  operation.  Six  weeks  after  operation  a  tuberculous  peritonitis  of  the  ascitic 
variety  developed,  a  second  operation  was  performed,  but  death  occurred  fourteen 
weeks  after  the  original  operation. 

I  These  were  two  of  our  earlier  cases,  and   with  our  present  knowledge   would 
not  be  given  ether. 


308        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

LITERATURE 

i.     Brown,  L.    Jr.  Am.  Med.  A.     1915.    64:1977. 

2.  Hewitt,  F.  W.     Anesthetics  and  Their  Administration.     London. 

1912.    p.  163. 

3.  Gwathmey,  J.  T.,  and  Baskerville,  C.    Anesthesia,  D.  Appleton 

and  Co.,  New  York  and  London.     19 14.     p.  329. 

4.  Magaw,  A.     Mayo  Clin.     191 1.    p.  573. 

5.  Doderlein  und  Kronig.     Operative  Gynecology,   191 3. 

6.  Zweifel.    Arch.  f.  Gyn.    No.  93. 

7.  Wahlander.     Inaug.  Dis.     1893. 

8.  Mayer,  A.    Gyn.  Rundsch.     191 1.    No.  5. 

9.  Furniss,  H.  D.    Am.  Jr.  Obst.     1913.     67:910. 

10.  Weil,  F.    Munch.  Med.  Woch.     19 10.     No.  7. 

11.  Prochownik,  L.    Zentrbl.  f.  Gyn.     1913.    37:    No.  7. 

12.  Kinghorn,  H.  M.    Jr.  Am.  Med.  A.     1916.    67:1842. 


CHAPTER  XIV 

TUBERCULOSIS  OF  THE  BREAST 

Histologic  study  of  tuberculosis  of  the  breast — Frequency — Primary  and  secondary 
infection — Routes  of  infection — Additional  foci  of  disease — Predisposing  causes — 
Age  incidence — Statistics — Varieties — Confluent — Disseminated — Physical  manifes- 
tations— Initial  symptoms — History  of  cases  noted — Tuberculosis  of  breast  in  com- 
bination with  true  neoplasms — Differential  diagnosis  between  tuberculosis  and  cer- 
tain cases  of  chronic  pyogenic  mastitis — Results  of  postoperative  treatment — Bibli- 
ography. 

HISTORICAL 

It  is  difficult  to  determine  who  was  the  first  to  describe  this  form  of 
tuberculosis.  In  1829  Sir  Astley  Cooper  1  wrote  of  a  "scrofulous  swell- 
ing of  the  bosom,"  which  doubtless  referred  to  this  condition.  In  i860 
Lancereaux  2  reported  a  case,  the  diagnosis  being  based  upon  macro- 
scopic findings.  Johannet,3  in  1853,  and  Valpeau,4  in  1854,  described 
this  condition.  Heyfelder  5  reported  a  case  occurring  in  a  man  of  26 
years.  Horteloup,6  in  1872;  Poirier,7  in  1883;  Demme,8  in  1889;  Hebb,9 
in  1893;  Khesin,10  Schede,11  in  1893;  Ferguson,12  in  1898;  Parsons,13 
Delbet,14  in  1892,  and  Ressigue,15  also  reported  cases.  In  1881 
Dubar16  reported  a  case  verified  by  bacteriologic  and  histologic  exam- 
inations. This  is  perhaps  the  first  authentic  case  recorded.  In  1883 
Ohnacker  17  reported  two  cases,  one  of  which  was  proven  by  animal 
inoculation. 

Frequency. — Tuberculosis  of  the  breast  is  a  rare  form  of  infection. 
Among  196  specimens  of  various  breast  lesions  in  the  gynecological 
laboratory  at  the  University  of  Pennsylvania,  there  was  one  example  of 
tuberculosis.  A  further  analysis  shows  91  malignant  breast  tumors,  75 
benign  breast  tumors,  29  inflammatory  lesions  (other  than  tuberculous), 
and  1  tuberculosis. 

Deaver  and  Herman 18  observed  five  cases  of  tuberculosis  of  the 
breast  in  a  series  of  600  operative  cases  of  mammary  disease.  This  was 
less  than  1  per  cent  of  all  cases  and  constituted  2.5  per  cent  of  the  benign 
lesions.  Bloodgood  19  found  tuberculous  mastitis  in  6  per  cent  of  all 
benign  lesions  of  the  breast  admitted  to  the  Johns  Hopkins  Hospital. 
Scott20  gives  the  following  table: 

309 


310        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Acute  mastitis  (abscess)   380  cases 

Chronic 79  cases 

Benign  tumors  (including  cysts)  . 296  cases 

Malignant  tumors 105 1  cases 

Tuberculosis 24  cases 


1830 


Scott  thus  found  tuberculosis  present  in  1.3 1  per  cent  of  a  series  of 
1830  cases  of  mammary  lesions,  and  in  3.17  per  cent  of  the  benign  cases. 
Bull,21  in  185  cases  of  mammary  disease  requiring  amputation,  observed 
one  specimen  of  tuberculosis.  .  Thus,  among  281 1  breast  lesions,  tuber- 
culosis was  present  in  thirty-six,  or  about  1.31  per  cent  of  all  cases. 

Many  cases  are  recorded  as  tuberculosis,  in  which  the  diagnosis  is 
open  to  doubt.  Durante  22  gives  notes  regarding  1 50  cases  and  adds  2 
of  his  own.  In  some  of  these  cases  the  diagnosis  is  not  positively  proven. 
No  case  should  be  considered  to  be  of  tuberculous  origin  unless  on 
positive  histologic  or  bacteriologic  findings.  In  1891  Roux  23  accepted 
31  cases,  at  the  same  time  recording  3  of  his  own.  In  1904  Anspach,24 
in  a  careful  review  of  the  literature  pertaining  to  this  subject,  was  willing 
to  accept  42  cases  as  authentic,  to  which  number  he  added  1  of  his  own. 
Ten  years  later,  Deaver  and  Herman,18  taking  Anspach's  series  as  a  basis, 
were  able  to  collect  87  cases,  to  which  they  added  5  new  ones.  Powers,25 
Scudder,26  Bartsch,27  Scott,20  Schley,28  Geissler,29  Brandle,30  Tuller,31 
Bender,32  and  Miles  33  have  contributed  valuable  articles  to  the  literature 
of  this  subject. 

Primary  and  Secondary  Forms. — Like  a  similar  infection  in  other 
parts  of  the  genital  tract,  tuberculosis  of  the  breast  may  be  either  primary 
or  secondary,  the  latter  being  by  far  the  most  frequent.  Indeed,  so  rare 
is  the  former,  that  its  existence  has  been  denied  by  such  authorities  as 
Klebs  (quoted  by  Deaver  and  Herman18),  Ribbert  (quoted  by  Deaver 
and  Herman18),  and  later  by  Spediacci 34  and  others.  A  number  of 
cases  of  indisputable  primary  origin  have,  however,  been  recorded  in 
recent  years.  Demme  (quoted  by  Schmidt35),  Orthmann,36  Kramer,37 
and  others  have  recorded  cases  in  which  the  organisms  have  gained 
entrance  through  abrasions  about  the  nipple.  Indeed  it  is  claimed  by 
Babes 38  that  the  tubercle  bacillus  is  capable  of  passing  through  the 
normal  skin.  Certainly  direct  infection  of  the  breast  through  abraded 
surfaces,  such  as  cracks  in  the  nipples,  must  be  regarded  as  the  most 
frequent  avenue  of  infection  of  the  primary  variety.  Deaver  and  Her- 
man 18  state  that  in  rare  instances  tuberculous  infection  via  the  lactiferous 


TUBERCULOSIS  OF  THE  BREAST  311 

ducts  incites  a  primary  focus  in  the  alveoli  of  the  breast.  Verneuil 39 
and  Verchere  40  have  reported  cases  of  ductile  infections. 

In  the  case  of  secondary  infection,  the  tubercle  bacilli  are  as  a  rule 
carried  to  the  breast  by  way  of  blood  or  lymph  channels  from  more  or 
less  distant  foci.  In  rare  instances  a  secondary  infection  may  perhaps 
result  from  a  direct  extension  from  a  nearby  focus. 

This  is,  however,  relatively  infrequent.  In  the  lymphogenic  form  of 
infection  any  of  the  lymphatics  of  the  axillary,  cervical  and  retrosternal 
nodes  and  those  in  the  neighborhood  of  ribs,  sternum,  pleura  and  larynx 
may  play  an  important  part.  It  must  be  remembered  that  probably  the 
tubercle  bacilli  may  in  some  instances  pass  through,  or  laterally  to,  lymph 
glands  without  the  latter  showing  macroscopic  or  even  microscopic  in- 
volvements. It  is  well  known  that  the  cervical  lymph  nodes  may  be 
attacked  by  tubercle  bacilli,  which  have  gained  entrance  through  the 
tonsils,  and  yet  the  latter  may  be  apparently  normal. 

Routes  of  Infection. — These  naturally  vary.  In  the  primary  variety 
a  direct  infection  from  without  occurs,  either  through  abrasions  of  the 
skin  covering  the  breast  or  nipple,  or  perhaps,  in  rare  instances,  through 
the  lactiferous  ducts.  Cracks  in  the  nipple  are  the  most  frequent  route 
of  ingress  of  the  primary  form.  The  so-called  primary  secondary  form 
of  infection,  which  has  been  described  in  a  previous  chapter,  is  also 
possible,  that  is,  a  patient  with  a  pulmonary  lesion  may  cause  an  infection 
of  this  region  by  means  of  contaminated  fingers,  etc.,  the  tubercle  bacilli 
being  on  the  hands  or  clothing,  and  these,  brought  in  contact  with  a 
fissure  of  the  nipple,  may  lead  to  a  mammary  tuberculosis.  The  route 
taken  by  the  infection  in  the  secondary  case  is  less  certain.  In  not  a  few 
cases  of  the  latter  variety,  the  axillary  glands  are  attacked  before  the 
breast.  In  other  cases,  the  routes  have  evidently  been  by  way  of  the 
cervical  lymph  nodes.  Cignozzi,41  Bahaud,42  Scott,20  Brandle,30  and 
Deaver  and  Herman  18  state  that  the  cases  in  which  the  axillary  nodes 
escape,  merely  support  the  well  known  pathologic  fact  that  lymphatic 
nodes  may  transmit  infectious  organisms  without  becoming  involved  in 
the  disease  process.  The  most  frequent  route  is  probably  by  way  of  the 
communicating  trunks  between  the  retrosternal  lymphatics  and  those  of 
the  breast.  These  branches  follow  the  mammary  branches  of  the  internal 
mammary  artery.  In  many  cases  it  is  impossible  to  determine  the  course 
by  which  the  infecting  organisms  have  reached  the  breast.  Cases  have 
been  recorded  as  secondary  to  tuberculous  arthritis  by  Khesin.10  Abra- 
ham,43 and  Hardouin  and  Marquis,44  but  these  are  probably  in  many  in- 
stances really  secondary  to  small  quiescent  pulmonary  lesions,  the  in- 
fection occurring  through  the  lymph  or  blood  channels. 


312        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Among  29  cases  collected  from  the  literature  by  Deaver  and  Herman, 
and  which  were  believed  to  be  of  the  secondary  variety,  the  following 
additional  foci  of  disease  were  present : 

Cases 

Bilateral  axillary  lymphadenitis 4 

Pulmonary  tuberculosis    4 

Cervical    lymphadenitis    5 

Tuberculous  osteitis  of  the  ribs   '3 

Tuberculous  osteitis,  bones  of  jaw  and  forearm   1 

Axillary    adenitis    5 

Cold  abscesses  of  forearm 1 

Tuberculous    infectious    maxillary    bone    and    cervical 

lymphadenitis 1 

Pleurisy    1 

Tuberculous  osteitis  of  hip  joint    1 

Pulmonary  tuberculosis  and  osteitis  of  phalanges  ...  1 
Entire  axilla  filled  with  tuberculous  lymph  nodes  ....  1 
Tuberculous  osteitis  of  knee  joint 1 

29 

Predisposing  Causes. — As  would  be  expected,  tuberculosis  of  the 
breast  is  extremely  rare  in  the  male  sex.  Among  the  150  cases  collected 
by  Durante,22  6  occurred  in  men.  Deaver  and  Herman  found  10  cases 
and  some  of  these  are  not  positively  proven.  According  to  these  authors, 
cases  occurring  in  men  have  been  recorded  by  Heyfelder,5  Ferguson,12 
Ressigue,15  Poirier  7  (quoted  by  Deaver  and  Herman),  Hebb,9  Schede,11 
Demme    (quoted  by  Schmidt35),  Parsons,13  and  Khesin.10 

Age. — Tuberculosis  of  the  breast  is  most  frequent  between  20  and 
50  years  of  age,  in  other  words  during  the  period  of  active  sexual  life. 
A  combination  of  the  statistics  of  the  primary  and  secondary  cases 
previously  recorded  by  Deaver  and  Herman  shows  the  following  results : 

Age  Incidence 

1  o  to  20  years 5 

20  to  30  years 19 

30  to  40  years 23 

40  to  50  years 16 

50  to  60  years 7 

60  to  70  years 3 

Not  mentioned    I 


TUBERCULOSIS  OF  THE  BREAST  313 

Demme  8  has  recorded  a  remarkable  case,  occurring  in  a  male  child 
four  days  old. 

Anspach  24  analyzed  the  reports  of  40  cases  and  found  that 

Per  cent 

28  were  married 70 

19  had  borne  children 47.5 

12  were  single 30 

12  had  hereditary  taint 30 

6  gave  histories  of  trauma 30 

8  suffered  from  mastitis  during  lactation 20 

2  were  directly  inoculated 5 

Deaver  and  Herman's  statistics  of  both  primary  and  secondary  cases 
show :  Cases 

Single 13 

Married    45 

Widowed   2 

Males   2 

Not  mentioned 2 

Multiparous 4° 

Parous    31 

Many  authors  attempt  to  divide  these  cases  into  primary  and  second- 
ary. As  already  stated,  we  are  of  the  opinion  that  the  great  majority 
are  secondary,  even  those  cases  which  are  apparently  primary;  and 
because  of  this  uncertainty  no  attempt  has  been  made  in  our  study  to 
separate  the  two  forms.  In  this  connection  Deaver  and  Herman's  sta- 
tistics are  of  interest,  in  that,  in  their  analysis  of  primary  cases,  51.1 
per  cent  were  parous,  whereas  in  the  secondary  cases  only  27.5  per  cent 
had  borne  children — a  significant  study,  for  in  the  primary  cases  direct 
infection  occurs  chiefly  through  a  crack  in  the  nipple,  which  lesion 
naturally  would  be  expected  to  be  much  more  frequent  in  the  women 
who  have  borne  children,  as  it  is  in  the  puerperium  that  abrasions  at  or 
about  the  nipples  are  most  prone  to  occur. 

Trauma. — The  actual  part  played  by  trauma  is  difficult  to  determine, 
but  it  is  probably  not  as  great  as  thought  by  some  authorities.  The 
general  surgical  principles,  however,  that  trauma  predisposes  to  tuber- 
culosis in  those  persons  already  infected,  probably  holds  as  true  in 
tuberculosis  of  the  breast  as  in  other  areas  in  the  body,  and  undoubtedly, 
if  a  latent  focus  of  tuberculosis  is  present  in  the  breast,  trauma  is 
especially  prone  to  light  it  up.  Deaver  and  Herman  found  that  13.3 
per  cent  of  their  primary  cases  gave  a  history  of  suppurative  mastitis, 


314        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Scudder,20  18.8  per  cent  of  his,  and  Von  Eberts,45  20  per  cent,  and  of 
inflammation  of  some  sort  complicating  lactation  42  per  cent.  In  this" 
connection  Scott's  20  case  is  a  remarkable  one ;  the  patient,  aged  34, 
pierced  her  breast  with  a  needle,  suppuration  followed,  and  a  sinus  per- 
sisted. An  area  of  induration  developed,  and  the  axillary  glands  became 
enlarged.  Tuberculosis  was  demonstrated  by  histologic  examination  of 
the  tissue. 

Varieties. — Various  classifications  for  the  tuberculous  lesions  oc- 
curring in  the  breast  have  been  suggested.  Perhaps  the  most  simple  and 
satisfactory  is  that  which  divides  them  into  (1)  confluent  and  (2) 
disseminated. 

Confluent  Variety. — This  type  results  from  either  a  pure  or  a 
mixed  infection,  the  latter  being  by  far  the  most  frequent.  In  some  cases 
only  a  small  localized  lesion  is  present,  whereas  in  others  the  disease 
progresses  until  the  entire  breast  is  involved.  In  some  instances  the 
entire  mammary  gland  is  apparently  spontaneously  attacked.  In  ad- 
vanced cases  fistulas,  retraction  of  the  nipples,  profuse  discharge  with  its 
accompanying  pruritus,  involvement  of  the  axillary  or  other  adjacent 
lymphatic  glands  occur.  Discrete  nodules  varying  in  size  are  probably 
the  most  frequent  lesions. 

The  method  by  which  the  breast  is  attacked  by  the  tubercle  bacillus  is 
similar  to  that  usually  observed  in  other  organs,  and  differs  only  because 
of  anatomic  conditions  present  in  this  region.  The  invading  organisms 
are  generally  enmeshed  in  the  stroma  of  the  gland.  Here  they  develop 
and  produce  typical  tubercles.  These  gradually  increase  in  size,  owing 
to  the  development  of  new  tubercles  forming  in  the  periphery.  In  this 
way,  in  a  variable  length  of  time,  usually  some  months,  a  palpable  mass 
may  be  formed.  In  the  meantime  fresh  areas  of  infection  are  probably 
developing  in  other  portions  of  the  breast,  so  that  in  the  later  stages 
multiple  nodules  varying  in  size  are  likely  to  be  observed.  At  a  still  later 
stage,  the  center  of  the  nodules  may  break  down  and  the  contents  find  its 
escape  through  the  skin.  This  results  in  a  sinus,  which  generally  exhibits 
little  tendency  to  close  spontaneously.  If  examined  at  this  stage,  the 
sinus,  of  varying  length,  may  be  found  leading  down  to  an  apparently 
small  collapsed  abscess  cavity,  the  walls  of  which  are  usually  hard  and 
indurated.  The  pus  is  often  yellowish,  or  brownish,  and  may  contain 
cheesy  particles.  As  a  result  of  the  irritating  properties  of  the  discharge, 
the  skin  is  likely  to  be  inflamed,  especially  in  neglected  cases.  Owing  to 
absorption  of  purulent  material,  the  axillary  lymphatics  are  nearly  always 
enlarged.  This  is  the  most  frequent  variety.  Sections  of  the  breast  may 
show  tubercles  in  various  stages  of  development. 


TUBERCULOSIS  OF  THE  BREAST  315 

The  so-called  "cold  abscess,"  the  result  of  an  unmixed  tuberculous 
infection,  is  rare.  It  presents  the  usual  character  of  such  a  lesion,  gen- 
erally as  a  smooth,  fluctuant,  elastic  swelling  covered  by  an  intact  and 
sometimes  normal  appearing  skin  and  surrounded  by  little  or  no  palpable 
induration.  The  veins  under  the  skin  are  often  dilated  and  visible.  The 
axillary  glands  are  rarely  involved  by  this  variety,  unless  sinuses  are 
present.  Sinuses  from  such  abscesses  are  common  and  often  persist 
over  long  periods. 

Disseminated  Variety. — There  is,  as  a  rule,  not  much  enlargement 
of  the  breast,  and  the  nipple  and  skin  covering  the  gland  is  normal. 
Scattered  throughout  the  breast  are  isolated  tuberculous  lesions  in  various 
stages  of  advancement.  These  usually  appear  as  small  nodules,  often 
whitish  or  yellowish  in  color,  and  may,  on  section,  contain  cheesy 
material.  The  course  is  generally  extremely  chronic.  Scott  has  described 
a  third  variety,  known  as  sclerosing  tuberculous  mastitis,  which  he  com- 
pares to  the  fibroid  form  of  pulmonary  tuberculosis.  To  this  list  Ingier  46 
has  added  a  fourth  form,  to  which  he  has  given  the  name  of  mastitis 
tuberculosa  obliterans.  Various  combinations  of  the  several  forms  have 
been  described. 

Scott  states  that  in  10  of  his  27  cases  the  most  prominent  histologic 
feature  was  a  diffuse  sclerosis.  In  3  of  these  cases  there  were  deep 
seated  abscesses,  whereas  in  4  others  superficial  abscesses  were  present. 
In  the  remainder  solid  neoplastic  lesions,  which  were  at  first  mistaken  for 
carcinoma,  were  removed.  If  it  is  to  be  employed  at  all,  it  is  to  the  latter 
class  of  cases  that  the  term  sclerosing  tuberculosis  should  be  applied. 
More  or  less  sclerosis  is  present  in  practically  all  cases.  The  writer  has 
had  the  opportunity  to  examine  only  6  cases  of  tuberculosis  of  the  breast, 
but  in  all  the  sclerosis  in  varying  degrees  was  more  or  less  marked.  Scott 
states  that  the  true  sclerosing  mastitis  is  most  likely  to  occur  in  elderly 
patients,  and  is,  as  in  his  case,  commonly  mistaken  for  cancer,  a  mistake 
which  is  generally  not  discovered  until  a  histologic  examination  of  the 
specimen  has  been  made.  This  variety  is  analogous  to  the  fibroid  lesions 
which  occur  in  the  lungs.  Tubercles  are  usually  few  in  number  or  may 
be  entirely  absent.  In  the  terminal  stage  the  breast  is  small,  hard  and 
misshapen.  The  nipple  is  often  retracted.  Tubercle  bacilli  are  present 
in  small  numbers.     Fistulas  rarely  occur. 

In  the  obliterating  tuberculous  variety  of  mastitis  of  Ingier  the  chief 
lesions  are  present  in  the  excretory  ducts  and  the  peri-acinous  connective 
tissue,  with  but  slight  involvement  of  stroma.  In  a  case,  the  history  of 
which  was  recorded  by  Ingier,  an  ulcer  was  present  which  had  destroyed 
the  nipple  and  part  of  the  adjacent  tissue.    The  granulation  had  spread 


316        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

inwards  and  involved  the  membrana  propria  of  the  smaller  ducts  and 
acini.  Proliferation  of  duct  epithelium  was  present  in  many  fields  and  re- 
sulted not  infrequently  in  obliteration  of  the  lumen.  The  case  is  de- 
scribed as  one  of  a  primary  infection  of  the  ducts. 

Symptoms. — The  majority  of  cases  of  tuberculosis  of  the  breast  are 
of  the  secondary  variety.  A  careful  examination  will  therefore  usually 
reveal  a  primary  lesion  or  a  history  suggesting  a  previous  infection  in 
some  other  part  of  the  body.  This  most  frequently  occurs  in  the  lungs, 
but  may  be  found  in  other  areas.  Occasionally  there  is  pain  on  deep 
inspiration,  and  in  these  cases  an  X-ray  should  be  taken  to  determine  the 
possible  existence  of  a  tuberculous  osteitis  of  the  ribs.  A  thorough  search 
for  a  primary  lesion  should  be  made.  The  primary  lesion  may  be  well 
developed  and  obvious,  or  it  may  exist  in  a  small  quiescent  focus,  the 
demonstration  of  which  is  difficult  or  perhaps  impossible.  A  history  of 
tuberculosis  in  the  patient's  family,  or  exposure  to  infection,  such  as 
living  with  tuberculous  individuals,  is  common.  No  age  is  immune,  but 
the  disease  is  most  frequent  during  the  active  sexual  life.  It  is  more 
common  in  the  married  than  in  the  single. 

Deaver  and  Herman's 18  combined  statistics  of  the  primary  and 
secondary  cases  show  the  initial  symptom  was  as  follows : 

Lump   5° 

Tender  lump   4 

Lump  in  neck  and  breast I 

Hardening I 

Acute  puerperal  mastitis    I 

Abscess  rupturing  spontaneously I 

Discharge  from  nipple I 

Pain   6 

Swelling  after  trauma   i 

Pain  and  hardening   3 

Not  mentioned    4 

Lump  in  axilla I 

74 
This  table  shows  that  in  the  great  majority  of  cases  a  swelling  or  tumor- 
like formation  is  the  most  frequent  initial  symptom.  This  was  the  first 
noticed  by  the  patient  in  55  or  74.32  per  cent  of  74  cases.  The  lump  is 
usually  painless,  although  trauma  not  infrequently  lights  up  a  more  acute 
inflammation.  Unfortunately  the  appearance  of  a  lump  is  also  the  most 
frequent  initial  symptom  of  all  breast  tumors,  and  is  therefore  of  little 
value  in  differential  diagnosis.     A  moderate  amount  of  pain  may  be 


TUBERCULOSIS  OF  THE  BREAST  317 

present  and  has  been  observed  in  about  36  per  cent  of  cases.  Retrac- 
tion of  the  nipples  in  the  case  of  Dubreuil,47  Verneuil,30  and  Warden  48 
occurred  respectively  1 1  months,  2  years,  and  5  years  prior  to  discovery 
of  tumor.  The  disease  usually  runs  a  moderately  rapid  course,  10  or 
1 1  months  being  the  average  duration  prior  to  operation,  it  being  in  this 
respect  more  rapid  in  evolution  than  even  cancer. 

The  general  condition  of  the  patient  is  frequently  good  and  even  in 
the  secondary  cases  is  often  fairly  satisfactory.  In  the  latter  variety,  the 
disease  exhibits  no  especial  tendency  to  occur  in  advanced  cases  of  pul- 
monary tuberculosis,  but  frequently  becomes  manifest  during  the  early 
stages  of  the  primary  lesion,  in  this  way  causing  further  difficulty  in 
differentiating  the  primary  from  the  secondary  cases.  Miles,33  in  his 
report  of  6  cases  of  tuberculosis  of  the  breast,  records  the  history  of  1 
remarkable  case  occurring  in  a  single  woman  49  years  of  age  and  2  years 
past  the  menopause,  in  which  there  was  retraction  of  the  nipple  and  an 
early  discharge  of  a  milk-like  secretion  through  the  nipple.  There  was 
no  swelling  or  pain,  but  two  years  later  the  lower  half  of  the  breast  was 
swollen,  tender,  and  the  seat  of  a  tumor  the  size  of  a  hen's  egg. 

As  already  stated,  the  initial  symptom  is  usually  the  discovery  of  a 
nodule  or  swelling  in  the  breast.  The  most  frequent  location  is  in  the 
upper  outer  quadrant,  although  any  part  of  the  breast  may.be  attacked. 

Among  the  74  cases,  37  occurred  on  the  right  side  and  28  on  the  left, 
1  case  was  bilateral,  and  in  8  the  side  attacked  was  not  mentioned. 

A  few  cases  have  been  recorded  in  which  both  breasts  were  attacked 
simultaneously.  Walther,49  Chiavarelli,50  Gilberti,51  and  Abraham 52 
have  observed  cases  in  which  first  one  breast  and  later  the  other  became 
invaded. 

The  condition  of  the  skin  in  this  series  was  as  follows : 

Adherent    9 

Reddened   3 

Red  and  tender 1 

Red  and  adherent  1 

Adherent  at  areola   1 

Darkened   1 

Dimpled   1 

Adherent  and  discolored  at  site  of  fistula 10 

Ulcerated  in  axilla   2 

Adherent  and  ulcerated   6 

Hard  and  discolored 1 

Abscesses  of  skin 1 


318        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Fistulas  were  present  in  37.4  per  cent  of  the  cases.  In  Scudder's  2C 
series  fistulas  were  present  in  over  50  per  cent,  and  nearly  all  had  en- 
largement of  the  axillary  lymphatic  glands.  Naturally  the  more  advanced 
the  case,  the  greater  the  likelihood  of  a  fistula  being  present.  The  nipple 
was  retracted  in  38.6  per  cent.  Palpable  enlargement  of  the  axillary 
lymphatic  gland  was  observed  in  63.8  per  cent  of  cases,  occurring  more 
frequently  (72.4  per  cent)  in  the  secondary  than  in  the  primary  cases. 

Scott,20  in  an  analysis  of  2.7  cases,  found  fistulas  present  in  35  per  cent, 
a  definite  history  of  injury  in  3  per  cent,  an  acute  onset  in  6  per  cent, 
skin  adherent  in  70  per  cent,  nipple  retracted  in  30  per  cent,  and  enlarge- 
ment of  the  axillary  glands  in  60  per  cent. 

The  important  symptoms,  therefore,  are  the  presence  of  a  lump,  fis- 
tulas, retraction  of  the  nipple,  and  enlargement  of  the  axillary  lymphatic 
glands.  These  symptoms  should  put  the  surgeon  on  his  guard  for  the 
possibility  of  tuberculosis  in  the  breast,  and  when  in  addition  they  occur 
in  a  woman  known  to  be  suffering  from  tuberculosis  elsewhere  in  the 
body,  they  must  be  looked  upon  as  extremely  suspicious. 

Tuberculosis  of  the  Breast  in  Combination  with  True  Neoplasms. 
— Tuberculosis  and  cancer  in  conjunction  have  been  observed  a  number 
of  times.  Klose  53  has  collected  17  cases,  many  of  them  not  above  sus- 
picion. He,  however,  reports  1  case,  and  Franco  54  has  observed  2.  Kil- 
lenberger,55  Scheidigger,56  Rodman,57  Bauer,58  Warthin,59  Moak,60  and 
Berger,61  have  also  recorded  cases.  Tuberculosis  of  the  breast  has  also 
been  observed  in  combination  with  benign  tumors.  Revel  62  has  recorded 
the  history  of  a  case  of  adenofibroma  associated  with  tuberculosis. 

It  will  be  observed  that  the  clinical  picture  is  in  many  cases  by  no 
means  diagnostic.  In  considering  the  treatment,  therefore,  the  variety  of 
tuberculosis  and  the  relative  frequency  of  true  tumors  of  the  breast  must 
be  taken  into  consideration,  and  no  valuable  time  should  be  lost  in  deter- 
mining the  character  of  the  lesion  beyond  possible  doubt. 

Diagnosis. — Owing  to  the  various  forms  in  which  tuberculosis  of 
the  breast  may  appear,  and  to  its  rarity,  the  diagnosis  is  often  difficult, 
and  it  may  readily  be  confused  with  a  variety  of  conditions,  among  the 
most  frequent  of  which  are  carcinoma,  fibro-adenoma,  retention  cysts 
which  have  undergone  suppuration,  simple  pyogenic  mastitis  either  of  the 
subacute  or  chronic  form,  and  less  frequently  sarcomata  and  other  malig- 
nant and  benign  tumors,  syphilis  and  actinomycosis. 

Some  forms  of  tuberculosis  are  indistinguishable  from  carcinoma 
prior  to  their  removal.  The  age  of  the  patient,  other  tuberculous  foci, 
and  in  rare  instances  the  demonstration  of  the  tubercle  bacilli  in  the  dis- 
charge from  the  lesion  are  diagnostic  points  of  value.     The  latter  is  of 


TUBERCULOSIS  OF  THE  BREAST  319 

course  positive  proof.  In  Duvergey's  63  case  the  diagnosis  was  confirmed 
by  the  demonstration  of  the  tubercle  bacilli  by  staining  methods  in  the  pus. 
In  Delfino's  64  and  Mantelli's  C5  cases  the  diagnosis  was  made  by  guinea 
pig  inoculation  with  pus  aspirated  from  the  abscesses  of  the  breast ;  and 
Davis  6G  demonstrated  the  organism  in  the  discharge  from  the  nipples 
in  a  case  of  tuberculous  mastitis.  Biopsy  may  be  of  value  in  certain  cases, 
but  it  should  be  remembered  that  malignant  disease  is  far  more  frequent 
than  tuberculosis,  and  when  a  suspicion  of  the  latter  exists,  it  is  better  to 
err  on  the  side  of  radicalism  than  on  that  of  prolonged  palliative 
treatment.  In  the  event  of  a  suspicion  of  syphilis,  the  Wassermann  re- 
action will  naturally  be  of  value,  as  well  as  the  history  and  the  exhibition 
of  antisyphilitic  remedies.  Actinomycosis  of  the  breast  is  an  extremely 
rare  condition,  only  a  few  cases  being  on  record.  If  in  the  latter  con- 
dition a  sinus  exists,  the  discharge  may  contain  ray  fungus. 

The  differential  diagnosis  between  tuberculosis  and  certain  cases  of 
chronic  pyogenic  mastitis,  especially  when  sinuses  have  formed,  is  im- 
possible without  laboratory  methods.  Under  such  circumstances  smear 
preparations  and  animal  inoculation  should  be  made.  As  a  final  step,  a 
small  piece  of  tissue  may  be  excised  for  histologic  examination.  More 
numerous  and  more  typical  organisms  are  likely  to  be  present  in  the  wall 
of  the  abscess  than  in  the  actual  pus;  for  this  reason  when  obtaining 
material  for  examination,  it  is  usually  advisable  to  lightly  curette  the 
walls  of  the  abscess  or  of  the  sinus,  rather  than  use  the  discharge  only. 

In  general,  it  should  be  remembered  that  tuberculosis  is  a  rare  dis- 
ease, whereas  tumors  of  the  breast  are  frequent.  In  doubtful  cases  and 
especially  in  patients  presenting  a  lump  in  the  breast  who  are  at  or  near 
the  cancer  age,  no  valuable  time  should  be  lost  in  establishing  the  char- 
acter of  the  lesion  under  suspicion,  beyond  the  question  of  a  doubt,  and 
it  is  under  these  circumstances  safer  to  err  on  the  side  of  radicalism  rather 
than  to  run  the  risk  of  palliating  a  possible  malignant  neoplasm. 

Treatment. — This,  as  in  other  forms  of  tuberculosis,  must  depend 
largely  upon  whether  the  case  be  a  primary  or  secondary  one,  and  in  the 
latter  event  upon  the  condition  of  the  primary  focus.  In  all  primary 
cases  operation  offers  an  excellent  hope  of  cure.  The  choice  of  operation 
must  vary  with  the  individual  case ;  in  young  patients,  and  when  the 
lesion  is  localized,  excision  is  probably  the  operation  of  choice.  In  older 
patients,  or  when  the  lesion  is  extensive,  amputation  of  the  breast  is  more 
satisfactory.  In  secondary  cases  the  same  lines  of  treatment  hold  good 
in  the  majority  of  cases,  the  danger  of  recurrence  or  of  the  development 
of  other  secondary  foci  must,  however,  be  taken  into  consideration. 
These,  however,  are  not  especially  great,  certainly  not  more  than  encoun- 


32  3    GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

tered  when  operating  upon  other  secondary  lesions,  such  as  tuberculous 
salpingitis  or  tuberculous  bone  disease,  whereas  the  results  of  the  opera- 
tion per  se  are  usually  good,  and  relief  of  symptoms  permanent.  With 
secondary  cases  which  are  associated  with  an  advanced  or  active  primary 
lesion,  the  surgeon  must  be  guided  by  the  conditions  of  the  individual 
case  and  treat  the  patient  accordingly. 

When  enlarged  axillary  glands  are  present,  these  should  be  removed, 
and  as  such  involvement  is  usually  present,  this  is  generally  a  necessary 
step  to  the  operation.  In  those  rare  cases  which  present  only  a  chronic 
abscess,  incision  and  drainage  are  preferable  to  excision.  Iodoform  is 
often  valuable. 

The  postoperative  treatment  is  important.  It  is  safer  to  consider  all 
cases  as  secondary  ones  and  treat  accordingly,  for  as  has  been  stated, 
small  primary  lesions  may  be  present  which  are  almost  impossible  to 
demonstrate,  and  these  may  exhibit  activity  subsequent  to  operation. 
For  this  reason,  all  cases  should  receive  an  extensive  course  of  hygienic 
and  dietary  treatment,  preferably  under  the  care  of  a  skilled  internist. 
The  exhibition  of  tuberculin  is  recommended  by  many  authorities,  and 
probably  has  some  value  in  increasing  the  resistant  powers  of  the  patient 
and  aiding  nature  to  overcome  any  small  areas  of  tuberculosis  which 
may  have  escaped  the  knife.  Indeed  von  Eberts  45  advises  tuberculin 
alone  in  early  cases. 

End  Results. — Owing  to  the  paucity  of  material,  accurate  statistics 
regarding  the  end  results  are  difficult  to  obtain.  The  immediate  mor- 
tality and  morbidity  following  operation  is  small.  Recurrences  have, 
however,  been  recorded  by  Stromberg  and  Kassagledov,67  and  by  Rabin- 
sohn  68.  In  12  cases  collected  from  the  literature  by  Anspach,24  4  were 
well  1  year  after  operation,  3  were  not  heard  from,  1  died  at  the  end  of  3 
years  from  an  unknown  cause,  and  the  remainder  were  well,  8,  4,  3, 
and  2  years  afterward  respectively.  In  the  primary  cases,  or  in  those 
secondary  cases  in  which  the  primary  focus  of  infection  is  small  and 
quiescent,  the  results  are  as  a  rule  excellent.  In  the  secondary  cases 
the  results  are  naturally  less  satisfactory  than  in  the  primary,  the  prog- 
nosis in  this  class  of  cases  depending  largely  upon  the  character,  activity, 
location  and  extent  of  the  primary  lesion,  and  the  patient's  ability  and 
willingness  to  adopt  proper  treatment.  A  number  of  instances  have  been 
recorded  in  which  other  secondary  lesions,  such  as  peritonitis,  menin- 
gitis, or  acute  miliary  tuberculosis  have  subsequently  developed,  but  in 
these  cases  such  complications  probably  occur  independently  of  the  mam- 
mary condition. 


TUBERCULOSIS  OF  THE  BREAST  321 

LITERATURE 

1.  Cooper,  Sir  A.     Illustrations  of  Diseases  of  the  Breast.    London, 

1829. 

2.  Lancereaux.     Bui.  soc.  anat.  de  Paris,     i860. 

3.  Johannet.     Rev.  Med.  et  Chir.     1853. 

4.  Velpeau.     Traite  des  maladies  du  sein  et  de  la  region  mammaire. 

i854. 

5.  Heyfelder.     Deutsch.  Klin.     185 1.     3:590. 

6.  Horteloup.     Des  tumeurs  du  sein  chez  l'homme.     1892. 

7.  Poirier.    These  de  Paris,     1883. 

8.  Demme.     Schmidt's  Jhrb.     1891.     p.  229. 

9.  Hebb.    Tr.  London  Path.  Soc.     1892-93.     44:123. 

10.  Khesin.     Kir.     1909.     25 :552. 

11.  Schede.     Deutsch.  Med.  Woch.     1893.     l9-     P-  I3l6- 

12.  Ferguson.    Jr.  Am.  Med.  A.     1898.     30:1412. 

13.  Parsons.    Brit.  Med.  Jr.     1907.    2:263. 

14.  Delbet.     Quoted  by  Duplay  and   Reclus.     Traite   de   chirurgie. 

1892. 

15.  Ressigue.     Alb.  Med.  Ann.     1909.     30:671. 

16.  Dubar.     These  de  Paris.     1881. 

17.  Ohnacker.     Arch.  f.  Klin.  Chir.     1883.     28:366. 

18.  Deaver,  J.   B.,  and  Herman,  J.  L.     Am.  Jr.   Med.   Sc.      1914. 

147  :i57- 

19.  Bloodgood.     In  Kelly  and  Noble's  Gynecological  and  Abdominal 

Surgery.     Philadelphia  and  London.     1908. 

20.  Scott.     St.  Barth.  Hosp.  Rep.     1905.     40:97- 

21.  Bull.     Q;uoted  by  Anspach.     No.  24. 

22.  Durante,  L.     Policlin.     1914.    21:  July. 

23.  Roux.    These  de  Geneve.     189 1. 

24.  Anspach,  B.  M.     Am.  Jr.  Med.  Sc.    July,  1904. 

25.  Powers.     Ann.  Surg.     1894.     19:159- 

26.  Scudder.     Am.  Jr.  Med.  Sc.     1898.     116:75. 

27.  Bartsch.     Inaug.  Dis.  Jena,  1901. 

28.  Schley.     Ann.  Surg.     1903.     37:510. 

29.  Geissler.    Deutsch.  Med.  Woch.     1906.    32:1780. 

30.  Brandle.     Beitr.  z.  Klin.  Chir.     1906.     50.     p.  215. 

31.  Tuller.     N.  Y.  Med.  Jr.     1909. 

32.  Bender,  X.     Rev.  de  chir.  et  de  chir.  abd.      1915.      13:265. 

33.  Miles,  A.    Edinb.  Med.  Jr.     1915.     14:205. 

34.  Spediacci.     Schmidt's  Jhrb.     1895.     247:148. 


322        GYXECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

Schmidt.     Ber.  u.  d.  Thatkt.  d.  Jenner.  Spit.     Beru.     1889. 

Orthmann.     Virch.  Arch.     1885.    p.  365. 

Kramer.     Centrbl.  f.  Chir.     1888.     15.  p.  867. 

Babes.     Presse  med.     June  15,  1907. 

Verneuil.     Prog.  med.      1882.      10:580. 

Yekchere.     These  de  Paris.     1884. 

Cigxozzi.     Policlin.     1910.     17 :8i  1  ;  Rif.  med.     1910.    26:965. 

Bahaud.     Gaz.  med.  de  Nantes.     1906.     24:317. 

Abraham.     These  de  Paris.     19 10. 

Hardouin  et  Marquis.    Rev.  de  chir.     1908.    38:79. 

von  Eberts.     Am.  Jr.  Med.  Sc.     1909.     138:70. 

Ingier.     Virch.  Arch.     1910.     202:217. 

Dubreuil.     Gaz.  hebd.  des  sc.  med.     1890.      12:325. 

Warden.     N.  Y.  Med.  Rec.     Oct.,  1908. 

Walther.     Bull,  et  mem.  soc.  d'anat.  de  Paris.      1906.     32:1076. 

Chiavarelli.     Rev.  ven.  di  sc.  med.      1907.     47:424. 

Gilberti,  P.     Policlin.      1916.     23:321. 

Abraham.     These  de  Paris.     1910. 

Klose.     Beitr.  z.  Klin.  Chir.     1910.     66:1. 

Franco.     Virch.  Arch.     1908.    v.  193. 

Killenberger.    Quoted  by  Klose,  No.  53. 

Scheidigger.       Ein    Fall    von    Carcinom    und    Tuberkulose    der 

Gleichen  Mamma.     1904.     Saurlander  &  Co. 
Rodman.     Tr.  6th  Intern.  Cong,  on  Tuberc.     1908.     Also  N.  Y. 

Med.  Rec.     1908. 
Bauer.     Uber  Kombination  von  Carcinomen  under  Tuberkulose  in 

der  Mamma.     Gottingen,  1912,  L.  Hoffer. 
Warthin,  A.  S.    Am.  Jr.  Med.  Sc.     1899.     118:25. 
Moak,  H.     Jr.  Med.  Res.     1902.     8:128. 
Berger.     Rev.  gen.  de  clin.  et  de  therap.      1906.     20,  p.  22. 
Revel.     Trib.  med.      1908.     4,  p.  741. 
Duvergey.    Jr.  de  med.  de  Bordeaux.  191 1.     51,  p.  841. 
Delfino.    Gac.  d.  osp.     1906.    2y.gyj. 
Mantelli.     II.  morg.      1910.     42:96. 
Davis.     Med.  news.     June,  1897. 

Stromberg  and  Kasageldov.     Russk.  klin.  arch.     1909.     25:512. 
Rabinsohn.     Inaug.  Dissert.,  Konigsbr.  in  Prague.     191 1. 
Loumeau.     Gaz.  hebd.  des  sc.  med.     1917.     38:45. 
Victor,  J.  A.     N.  Y.  Med.  Rec.     1918.     94:829. 
Goxzalez-Marmol,  D.     Rev.  med.  cub.     1919.     30:209. 
Gulewood.    Jr.  Am.  Med.  A.     1916.    67:1660. 


CHAPTER  XV 

TUBERCULOSIS  OF  THE  PERITONEUM 

Early  history — First  authentic  operation  performed  by  Sir  Spencer  Wells — Primary 
intraperitoneal  foci — Primary  and  secondary  tuberculous  peritonitis — Cases  studied 
with  view  of  determining  primary  lesion — Routes  of  infection — Pathology — Classi- 
fication of  tuberculous  peritonitis — Varieties — Acute  miliary,  ascitic,  fibroplastic, 
and  suppurative — Latent  cases  accidentally  discovered — Frequency;  special  fre- 
quency among  colored  race — Variety  of  tubercle  bacillus  causing  tuberculous 
peritonitis — Division  into  groups — Histologic  study — Pseudotuberculosis  of  the 
peritoneum — Difficulties  encountered  in  differentiating  malignancy  from  tubercu- 
losis— Methods  of  treatment — Operative  complications — Tuberculosis  in  hernia — 
Reformation  of  ascites  following  operation — Comparison  of  results  of  medical 
and  surgical  treatment — Bibliography. 


HISTORY 

The  early  history  of  tuberculosis  contains  comparatively  few  refer- 
ences to  tuberculous  peritonitis,  despite  the  works  of  Bichat,  Laennac, 
Bayle,  and  others,  and  it  was  not  until  the  appearance  in  1825  of  Louis' 
dictum,  to  the  effect  that  chronic  peritonitis  was  usually  of  tuberculous 
origin,  that  the  attention  of  the  medical  profession  became  seriously 
directed  to  the  condition.  The  first  authentic  operation  performed  upon 
a  patient  suffering  from  tuberculous  peritonitis  is  the  now  celebrated 
case  of  Sir  Spencer  Wells.  On  Christmas  Eve,  1862,  Wells  operated 
upon  a  patient  of  the  surgeon  etcher,  Mr.  F.  Seymour  Haden.  The 
anesthetic  was  administered  by  Clover,  and  Savage  was  an  assistant. 
The  patient  was  operated  upon  under  the  mistaken  diagnosis  of  an 
ovarian  cyst,  and  is  referred  to  by  Wells  x  in  a  subsequent  publication. 
This  patient  recovered,  but  it  remained  for  Kronig  2  to  trace  the  sub- 
sequent history  and  thereby  adduce  the  positive  proof  of  an  ultimate 
cure — the  first  authentic  operative  cure  of  this  condition.  Credit  is  also 
due  Kronig  for  urging  operative  treatment  for  this  condition,  first  in 
1884  and  later  in  1890.  The  latter  paper  contained  a  report  of  139 
cases  operated  upon,  107  of  which  were  improved  or  well  2  or  more 
years  subsequent  to  operation;  and,  comparing  these  results  with  those 
obtained  by  medical  treatment,  Kronig  drew  an  analog}'  between  tuber- 

323 


324        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

culosis  of  the  peritoneum  and  a  similar  infection  of  the  joints,  the  opera- 
tive benefits  of  which  were  recognized.  This  paper  was  the  starting 
point  of  the  long  continued  discussion  as  to  the  relative  merits  of  the 
medical  and  surgical  treatment  of  tuberculous  peritonitis. 

Stone  3  has  called  attention  to  the  fact  which  has  been  overlooked  by 
many  historians  that  in  1884  Dr.  Z.  B.  Adams  of  Farmington  operated 
upon  a  patient  for  this  condition,  this  probably  being  the  first  operation 
performed  for  tuberculous  peritonitis  in  this  country.  It  is  worthy  of 
note  that  the  older  writers  considered  this  disease  fatal,  and  it  is  only 
with  the  advent  of  more  modern  surgical  treatment  that  a  more  opti- 
mistic attitude  has  been  assumed. 

Intraperitoneal  Foci. — Tuberculous  peritonitis  may  be  either  local 
or  general.  General  tuberculous  peritonitis  may,  as  a  result  of  healing, 
result  in  a  local  peritonitis.  The  reverse  is  even  more  frequent.  In  a 
previous  chapter  the  subject  of  tuberculous  salpingitis  and  pelvic  peri- 
tonitis has  been  discussed.  It  is  difficult  to  separate  these  two  conditions. 
In  women,  at  least,  the  fallopian  tubes  are  the  primary  intraperitoneal 
focus  in  the  majority  of  cases.  In  some  instances  the  disease  apparently 
limits  itself  to  the  genital  tract  and  to  the  peritoneum  of  the  pelvis,  never 
assuming  the  dimensions  of  a  general  peritonitis;  in  other  cases  it  begins 
as  a  salpingitis  and  remains  localized  for  a  longer  or  shorter  period,  and 
finally  becomes  general.  On  the  other  hand,  in  not  a  few  cases  of  macro- 
scopically  localized  tuberculous  peritonitis  which  have  undoubtedly 
originated  in  the  tubes  (primary  intraperitoneal  focus)  there  is  a  history 
which  indicates  that  at  some  stage  of  the  disease  there  has  been  a  general 
tuberculous  peritonitis,  the  salpingitis  remaining  after  the  general  peri- 
tonitis has  cleared  up.  Thus  the  intraperitoneal  infection  may  begin  as 
a  salpingitis  and  subsequently  develop  into  a  general  peritonitis;  or  it 
may  begin  as  a  general  peritonitis  which  undergoes  cure,  but  leaves  behind 
a  salpingitis.  One  or  more  attacks  of  general  peritonitis  may  occur 
during  the  course  of  a  tuberculous  salpingitis,  the  former  being  the  most 
frequent.  Schlimpert,4  in  a  long  series  of  postmortems,  found  that 
among  females  87.9  per  cent  of  the  cases  of  tuberculous  peritonitis  were 
secondary  to  genital  lesions,  the  tubes  being  the  infecting  foci  in  the 
great  majority  of  cases.  It  should  be  remembered  that  as  long  as  a 
tuberculous  focus  remains  in  the  peritoneal  cavity,  a  potential  factor  in 
the  production  of  a  general  peritonitis  is  present. 

Primary  and  Secondary  Tuberculous  Peritonitis. — Primary  tuber- 
culosis of  the  peritoneum  is  an  extremely  rare  condition — so  infrequent, 
in  fact,  that  before  accepting  such  a  case  as  authentic,  a  carefully  per- 
formed autopsy  is  necessary.    Cases  reported  without  necropsy,  although 


TUBERCULOSIS  OF  THE  PERITONEUM  325 

in  some  instances  probably  authentic,  are  open  to  doubt.  Borschke  5 
found  2  cases  which  he  considered  primary  in  226  necropsies  performed 
upon  subjects  dying  of  tuberculous  peritonitis.  The  lungs  were  involved 
in  200.  Hamman,6  in  35  similar  postmortems,  observed  1  case  in  which 
the  tuberculosis  was  limited  to  the  peritoneum.  In  this  case  there  was, 
however,  an  adhesion  in  the  pericardium  which  may  have  been  of  tuber- 
culous origin.  In  this  series  pulmonary  tuberculosis  was  present  in  18 
cases  and  in  29  either  the  pleura  or  pericardium  was  involved.  Miinster- 
mann  7  found  1  case  which  he  believed  primary  in  46  autopsies  upon 
subjects  dead  of  tuberculous  peritonitis.  So  infrequent  is  primary  tuber- 
culosis of  the  peritoneum,  that  its  existence  has  been  doubted  by  some 
authorities.  The  well  proven  fact  that  tuberculosis  under  certain  cir- 
cumstances can  pass  through  various  tissues  without  producing  definite 
lesions  therein,  is  however  proven  by  the  carefully  worked  out  postmortem 
results  of  many  observers  as  to  the  existence  of  primary  peritoneal  tu- 
berculous lesions.  Primary  peritoneal  tuberculosis  is  not  to  be  con- 
fused with  those  not  uncommon  cases,  in  which  the  primary  focus  has 
undergone  partial  resolution  or  is  in  abeyance  by  the  time  the  peritonitis 
has  become  manifest.  It  should  not  be  forgotten  that,  in  those' cases  in 
which  there  are  lesions  of  the  peritoneum,  as  well  as  in  other  areas  in 
the  body,  it  is  possible  for  the  peritoneum  to  be  the  primary  seat,  and  the 
other  foci  to  be  the  secondary.  Whereas  this  is  theoretically  possible, 
careful  study  has  shown  that  this  is  rarely  the  case,  the  reverse  being 
true  in  nearly  all  cases.  The  early  history  of  peritoneal  tuberculosis  con- 
tains accounts  of  many  cases  of  supposed  primary  tuberculous  peritonitis. 
Thus  Rokitansky 8  in  1855  was  °f  the  opinion  that  many  cases  were 
primary.  The  primary  form  is  probably  less  infrequent  in  young  chil- 
dren than  in  adults. 

The  lungs  are  the  primary  seat  in  the  great  majority  of  cases. 
Albrecht 9  studied  200  cases  of  peritoneal  tuberculosis  which  came*  to 
autopsy,  with  view  of  determining  the  primary  lesion,  with*  the 
results  shown  in  table  on  following  page. 

Matteson  10  was  able  to  demonstrate  tuberculosis  in  other  parts  of 
the  body  in  50  per  cent  of  his  cases  and  in  75  per  cent  of  those  cases 
which  were  under  30  years  of  age.  Matteson's  statistics  are  drawn  from 
operative  material,  and  hence  show  a  smaller  percentage  of  secondary 
cases  than  would  those  formulated  from  postmortems.  Among  Ham- 
man's'6  series  of  150  cases,  definite  physical  signs  of  pulmonary  tuber- 
culosis were  present  in  34  patients,  and  47  complained  of  cough. 

Routes  of  Infection. —  The  tubercle  bacilli  may  gain  access  to-  the 
peritoneum  by  means  of  the  blood  or  lymph  from  either  distant  or  ad- 


326        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 


Lungs 

Lymphatic  glands   

Intestines    

Genitalia     

Bones    

Pleura    

Tuberculosis  of  serous  membrane 
Unknown 


Women — per  cent 

46.1 
20.8 

7-7 
12. 1 

3-3 
3-4 
3-3 
3-3 


jacent  foci,  by  contiguity  or  continuity  from  other  foci,  or  by  direct 
implantation  upon  the  peritoneum,  either  from  without,  as  an  experi- 
mentally produced  peritonitis  in  animals  by  way  of  the  genital  tract,  or 
directly  through  normal  structures,  such  as  the  intestine  or  lymph  gland. 
The  passage  of  tubercle  bacilli-  through  normal  tissue  has  been  proven. 
Tubercle  bacilli  have  also  been  demonstrated  in  the  normal  fallopian 
tube. 

Practically  there  are  four  chief  routes  by  which  infection  occurs, 
( 1 )  by  the  blood  or  lymph  channels,  (2)  from  an  intestinal  lesion  through 
the  walls  of  the  gut,  (3)  from  a  tuberculous  mesenteric  gland,  (4)  from 
a  tuberculous  salpingitis.  Tubercle  bacilli'  may  pass  through  the  in- 
testinal wall  or  through  a  lymph  node  without  the  latter  being  seriously 
affected.     This  is  probably  of  rare  occurrence. 

The  acute  miliary  variety  of  tuberculous  peritonitis  is  the  result  of 
a  blood  borne  infection,  a  general  tuberculosis  usually  being  present  as 
well  as  the  peritoneal  involvement.  Tuberculous  peritonitis  in  men  is 
usually  secondary  to  an  intestinal  lesion,  often  an  ulcer,  and  generally 
located  in  the  neighborhood  of  the  cecum  or  vermiform  appendix.  In 
women,  the  fallopian  tubes  are  the  most  frequent  primary  intraperitoneal 
site,  although  the  appendix  and  cecum  are  not  uncommon  starting  points. 
In  children  the  infection  most  often  occurs  from  an  infected  mesenteric 
gland. 

Allshut 21  believes  that  the  path  of  infection  is  often  from  the  peri- 
bronchial lymph  tissue  through  the  perforating  lymphatics  of  the  dia- 
phragm into  the  peritoneal  cavity;  chiefly  by  the  retroperitoneal  lymph 
glands,  which  he  has  found  are  generally  involved.  In  rare  instances, 
according  to  Goodrich,12  infection  may  result  from  ulceration  or  infiltra- 
tion of  the  diaphragm.  Apert  (quoted  by  Goodrich12)  has  recorded 
the  history  of  such  a  case.     The  tonsils  are  often  the  entry  way  for  the 


TUBERCULOSIS  OF  THE  PERITONEUM  327 

tubercle  bacilli.  Cummins  (quoted  by  Goodrich12)  has  recorded  a 
series  of  cases  in  men,  in  which  the  infection  appears  to  have  been  sec- 
ondary to  a  tuberculous  epididymitis  by  way  of  the  lymph,  vessels  of  the 
spermatic  plexus. 

As  has  been  stated,  among  women  the  fallopian  tubes  are  the*  most 
frequent  primary  intraperitoneal  focus.  One  of  the  characteristics  of 
tuberculous  salpingitis-  is  that  the  abdominal  ostia  of  the  tubes  tend*  to 
remain  patulous,  a  point  favoring  the  spread  of  the  infection  to  the 
peritoneal  cavity.  The  involvement  is  generally  bilateral,  and  the' mucosa 
of  the  tubes  is  practically  always  involved,  two  conditions  also  favoring 
dissemination  of  the  infection  to  the  peritoneum.  When  a  tuberculous 
salpingitis  and  peritonitis  coexist,  undoubtedly  either  may  be  the  primary 
intraperitoneal  focus.  In  191 1  Kronig,2  in  the  German  Gynecological 
Kongress,  upheld  the  view  that,  when  these  two  conditions  occurred  to- 
gether, the  peritoneum  was  most  frequently  the  primary  infection. 
Albrecht  9  stated  that,  as  a  result  of  over  10,000  autopsies  and  from 
clinical  and  experimental  studies,  he  believed  the  two  conditions  frequently 
coexisted;  in  33  per  cent  it  would  seem  that  the  genital  lesion  was  the 
primary  one,  but  that  the  reverse  was  rarely  the  case,  and  when  a 
hematogenous  infection  occurred,  the  tubes  and  the  peritoneum  were 
frequently  simultaneously  involved.  Mayo 13  believes  the  fallopian 
tubes  the  most  frequent  intra-abdominal  site  in  women,  an  opinion  in 
which  the  author  concurs.  This  belief  is  based  upon  the  fact  that  in 
women  tuberculous  salpingitis  is  more  frequent  than  is  general  tuber- 
culous peritonitis,  tubercle  bacilli  being  the  exciting  cause  in  from  4  to 
8  per  cent  of  all  tubal  inflammations,  and  that  in  the  majority  of  cases 
of  tuberculous  peritonitis,  a  careful  search  in  the  history  will  reveal 
evidences  of  the  existence  of  a  salpingitis  some  time  prior  to  the  onset 
of  the  symptoms  of  the  general  peritonitis.  Mayo  13  states  that  in  a 
series  of  18  cases,  11  were  in  women,  in  9  of  whom  the  origin  was 
in  the  tubes,  1  in  the  vermiform  appendix,  and  1  unlocated;  in  the  7 
men,  3  originated  in  the  vermiform  appendix,  2  in-  the  cecum;  and  2 
were  unlocated.  Mayo  mentions  5  other  cases-  in  which  the  lesions 
were  most  severe  in  the  upper  abdomen,  the  primary  intraperitoneal  site 
of  which  was  unknown.  These  were  in  dlder  patients.  Kraus  14  has 
recorded  the  history  of  a  case  in  which  he  believed  that  the  adnexal  in- 
fection was  secondary  to  a  tuberculous  appendicitis. 

Pathology. — The  lesions  produced  by  the  tubercle  bacilli  in  the  peri- 
toneum are  in  general  similar  to.  those  resulting  from  a  similar  infection 
in  other  parts  of  the  body.  They  are,  however,  cfften  modified  owing  to 
the  peculiarities  of  the  intraperitoneal  viscera.     At  the  point  of  implanta- 


328        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

tion  a  typical  tubercle  is  developed.  In  the  miliary  (hematogenous) 
variety  of  infection  great  numbers  of  tubercles-  in  various  portions 
of  the  peritoneum,  as  well  as  elsewhere,  develop  simultaneously.  When 
the  inflammation  results  from  the  rupture  into  the  peritoneum  of  a  tuber- 
culous focus,  the  onset  may  be  general.  In  the  other  fojrms  of  infection 
the  lesion  is  probably,  as  far  as  the  intraperitoneal  condition  is  concerned, 
always  local  in  its  incipiency.  The  first  area  of  infection"  acts  as  a 
starting  point  from  which  other  tubercles  are  developed,  the  mfection 
being  sprread  through  the  peritoneal  cavity  by  peristaltic  and  respiratory 
movements,  the  peritoneal  currents,  gravity,  etc.  Tubercles  are  usually 
most  numerous  at  or  near  the  primary  intraperitoneal  foci.  The  tubercles 
may  be  seen  as  small,  elevated,  firm  areas,  varying  in  size  from  the  micro- 
scopic to  a  few  millimeters  or  more  in  diameter,  and  are  found  in  various 
stages  of  development.  Not  infrequently  nearby  tubercles  coalesce,  and 
in  this  way  massive  lesions  may  be  developed :  in  some  instances  these 
break  down  and  abscesses  of  various  size  result.  When  actual  suppura- 
tion takes-  place,  a  mixed  infection  is  nearly  always  present.  As  a  result 
of  the  inflammation,  peritoneal  cysts  may  develop;  these  are  often- thin 
walled  and  contain  thin,  clear,  amber  colored  fluid.  In  some  instances 
the  contents  are  turbid  and  discolored:.  Various  lesions  may  develop*; 
adhesions  are  the  most  frequent.  These  may  vary  from  a  few  light 
bands  of  adhesion  situated  at  the  point  of  the  primary  intraperitoneal 
focus,  to  great  masses  composed  of  plastered  together  intestines,  omentum, 
or  other  intraperitoneal  organs.  In  the  cavities  of  such  lesions,  ab- 
scesses, cysts,  fistulas  leading  to  adjacent  organs,  or  even  artificial 
anastomoses  may  be  present.  With  the  exception  of  the  fallopian  tubes, 
the  omentum  is  the  most  frequent  intraperitoneal  organ  attacked.  It 
may  be  adherent  to  some  other  focus,  such  as  the  cecum  or  tubes  or,  as 
is  not  infrequently  the  case,  may  be  found  rolled  up,  forming  a  more  or 
less  nodular  sausage  shaped  mass,  often  lying  diagonally  or  transversely 
in  the  upper  peritoneal  cavity.  On  palpation,  the  rolled  up  omentum 
often  simulates  a  true  neoplasm.  As  a  result  of  adhesions,  intestinal 
obstruction  may  result.  Indeed,  the  fact  that  obstruction  does  not  develop 
more  often  is  remarkable-,  when  the  frequency  and  character  of  the 
adherent  masses  often  formed  is  taken  into  consideration.  When  much 
free  fluid  is  present,  adhesions  are  less  likely  to  be  a  pronounced  feature. 
In  such  cases  the  various  organs  are  found  floating  free  m  the  fluid  and 
less  chance  for  fusion  is  afforded.  Occasionally  a  cure  of  the  general 
tuberculous  peritonitis  occurs,  but  a  local  lesion,  such  as  an  ulcer  or  a 
salpingitis,  persists.  This  may  remain  dormant,  producing  no,  or  only 
local,  symptoms  for  a  long  period  and  may  finally  undergo  resolution ; 


TUBERCULOSIS  OF  THE  PERITONEUM  329 

or  may  at  some  future  time  produce  a  focus  for  a  fresh  involvement 
of  the  general  peritoneal  cavity.  Not  infrequently  in  healed  cases  ad- 
hesions persist  and  may  result  in  troublesome  symptoms.  Strangulation 
of  the  gut,  stricture,  or  intestinal  obstruction  has  been  reported,  and  con- 
tractures resulting  in  painful  traction  upon  various  structures  are  of 
comparatively  frequent  occurrence. 

Many  classifications  of  tuberculous  peritonitis  exist.  Some  authorities 
consider  the  various  forms  separate  and  distinct,  whereas  many  believe 
them  to  be  but  different  stages  of  the  same  thing.  One  of  the  most 
widely  employed  classifications  is  that  which  divides  tuberculous  peri- 
tonitis into  the  (1)  acute  miliary,  (2)  ascitic,  (3)  fibroplastic,  and  (4) 
the  suppurative.  To  these  Bryant 15  adds  a  fifth  variety,  the  latent. 
Osier  16  classifies  tuberculous  peritonitis  as  follows  :  (1 )  serous,  exudative 
or  miliary,  (2)  nodular  or  ulcerative,  (3)  adhesive,  fibroplastic  or  cystic, 
and  (4)  purulent. 

Acute  Miliary  Variety. — In  this  variety  the  peritoneal  involve- 
ment is  usually  but  an  incident  to  a  general  infection,  and  for  this  reason, 
the  symptoms  of  the  peritonitis  are  often  masked  by  those  produced  by 
the  general  infection.  Death  may  supervene  before  the  peritoneal  in- 
volvement becomes  pronounced.  If  the  patient  survives  for  a  sufficiently 
long  time,  ascites,  with  its  accompanying  symptoms,  develops.  In  some 
cases  the  clinical  symptoms  are  suggestive  of  typhoid  fever.  This  form 
of  peritonitis  is  not  as  a  rule  amenable  to  surgical  treatment. 

Ascitic  Variety. — This  is  the  most  frequent  form  of  tuberculous 
peritonitis.  In  an  analysis  of  500  cases  by  Wunderlich  17  the  greatest 
number  were  found  to  be  the  ascitic  variety.  Stone,3  in  122  cases, 
found  fluid  in  the  peritoneal  cavity  in  84,  or  nearly  69  per  cent.  Ham- 
man,6  in  a  series  of  122  cases,  found  fluid  in  the  abdomen  in  42  per  cent. 
Among  103  cases  which  were  operated  upon  or  which  came  to  post- 
mortem, 35  cases  were  of  the  ascitic  variety.  Baisch,ls  in  an  analysis 
of  no  cases  from  the  Tubingen  Gynecological  Clinic,  found  the  ascitic 
variety  by  far  the  most  frequent.  In  a  series  of  21  cases  from  the  gyne- 
cological department  of  the  Hospital  of  the  University  of  Pennsylvania, 
about  60  per  cent  were  of  this  variety.  When  the  fallopian  tube  is  the 
primary  intraperitoneal  focus,  the  resulting  peritonitis  is  generally  of 
the  ascitic  variety,  so  that  this  variety  is  especially  common  in  women. 

Not  only  is  the  ascitic  variety  the  most  frequent,  but  it  is  also  the 
variety  which  offers  the  best  hope  for  surgical  cure.  As  a  general  rule, 
the  lower  half  of  the  peritoneal  cavity  is  the  area  chiefly  involved.  This 
is  especially  the  case  in  women  because  of  the  fact  that  the  fallopian 
tubes  are  so   frequently  the  primary  intraperitoneal   focus.     The  peri- 


330        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

toneum  is  more  or  less  thickly  studded  with  tubercles  in  various  stages 
of  development.  The  peritoneum  itself  becomes  thickened,  hyperemic, 
and  more  or  less  destruction  of  the  endothelial  layer  occurs.  The 
omentum  and  the  intestines,  especially  the  small  bowel,  tend  to  become 
adherent,  and  may  often  be  found  glued  together,  forming  tumor-like 
masses,  which  are  generally  pushed  upwards  by  the  exudate.  The  variety 
and  character  of  the  adhesions  vary  markedly.  In  addition  to  the 
omentum  and  intestines,  masses  may  be  composed  of  enlarged  mesenteric 
glands,  or  pseudo  tumors  may  be  the  result  by  fecal  impaction.  Probably, 
in  those  cases  where  the  effusion  occurs  early  the  fluid  is  found  more 
generally  distributed  and  there  are  fewer  adhesions,  whereas,  if  exudate 
is  formed  late,  adhesions  are  likely  to  be  a  pronounced  feature.  If  the 
fluid  is  encapsulated,  the  walls  of  the  cavity  are,  in  part  at  least,  com- 
posed of  adherent  coils  of  intestines,  omentum,  etc.  As  might  be  ex- 
pected, the  character  of  the  fluid  varies  considerably.  It  is  usually  clear, 
transparent,  straw  colored  fluid,  but  may  become  cloudy  or  turbid  from 
the  admixture  of  various  substances.  Not  infrequently  considerable 
flocculent  material  is  suspended  in  the  fluid.  From  the  admixture  of 
blood  the  fluid  may  be  reddish,  dark  brown  or  even  black.  If  walled 
off  cystic  spaces  are  present,  the  fluid  in  some  may  be  clear  and  in  others 
discolored.  When  few  adhesions  are  present  and  in  the  large  cystic 
spaces  the  fluid  is  prone  to  remain  clear,  whereas  in  the  small  compart- 
ment degenerative  changes  are  more  likely  to  occur  and  result  in  a  dark 
or  turbid  exudate.  The  fluid  often  contains  a  high  percentage  of 
lymphocytes.  The  amount  of  fluid  varies  considerably;  as  much  as  six  or 
eight  gallons  have  been  observed. 

Fibroplastic  Variety. — Of  Wunderlich's  500  cases,  136  were  of 
the  fibroplastic  variety.  Mayo  13  believes  that  while  the  ascitic  variety 
is  the  most  common  and  is  especially  prone  to  occur  in  conjunction  with 
lesions  of  the  fallopian  tube,  the  fibroplastic  is  more  frequent  as  a  result 
of  appendiceal  tuberculosis  or  in  those  cases  in  which  the  primary  intra- 
peritoneal focus  cannot  be  located.  A  mixed  infection  is  often  present 
and  operative  results  are  less  successful  than  in  the  previously  described 
form.  Stone,3  in  122  cases,  observed  2>7  °f  this  variety.  Hamman,8 
in  103  cases  which  came  to  operation  or  postmortem,  observed  63  that 
were  fibroplastic.  Baisch,18  in  no  cases,  observed  22  which  were  of  the 
fibroplastic  form. 

The  fibroplastic  variety  originates  as  a  localized  lesion,  in  adults  often 
in  the  appendiceal  region,  and  in  children  frequently  from  a  tuberculous 
mesenteric  gland.  From  the  primary  intraperitoneal  focus  the  disease 
spreads,  generally,  however,  exhibiting  a  tendency  to  remain  localized ; 


TUBERCULOSIS  OF  THE  PERITONEUM  331 

adhesions  of  intestinal  or  omental  origin  often  wall  off  collections  of 
fluid.  As  the  disease  advances,  caseation  and  ulcerations  occur,  and  some 
authorities  refer  to  this  stage  as  the  caseous  or  ulcerative  variety.  The 
ulcerations  may  perforate  and  result  in  a  general  peritonitis,  or  various 
forms  of  fistulas  may  occur.  Massive  inflammatory  products  may  be 
present;  the  peritoneum  is  thickened  and  more  or  less  profusely  studded 
with  tubercles  in  various  stages  of  development.  The  diseased  areas 
are  covered  with  yellowish,  whitish,  or  brownish  gelatinous  or  fibrous 
material,  often  thickly  plastered  over  the  intestines  and  peritoneum. 
As  a  result  of  this  process,  more  or  less  localized  areas  of  a  boggy  or 
semiflocculent  consistency,  composed  of  adherent  viscera  and  the  fibrous 
exudate,  are  found.  In  some  instances  the  fluid  is  more  or  less  absorbed ; 
the  endothelium  however  proliferates  and  the  new  tissue  undergoes 
cicatrization,  giving  rise  to  firm  adhesions  which  often  result  in  fecal 
accumulations  and  may  cause  intestinal  obstruction  or  stricture.  In  some 
localities  the  peritoneum  may  exhibit  advanced  evidence  of  the  disease, 
and  in  others  be  comparatively  or  even  entirely  normal.  Xothnagel 19 
states  that  cicatricial  contractions  are  specially  marked  in  the  mesentery 
and  omentum.  It  is  important  to  note  that  cicatricial  masses  develop 
more  rapidly  than  the  tubercles,  so  that  the  latter  become  encapsulated 
and  may  thus  disappear  and  constitute  a  more  or  less  complete  cure.  At 
operation  or  autopsy  no  tubercles  may  be  visible,  scar  tissue  being  the 
only  discernible  evidence  of  the  disease. 

Suppurative  Variety. — This  is  a  questionable  variety  and  in  nearly 
all  cases  is  really  an  end  stage  of  one  of  the  other  forms,  the  fibroplastic 
especially,  tending  to  result  in  suppuration.  In  this  variety  any  of  the 
lesions  previously  described  may  be  present.  It  is  always  the  result  of 
a  mixed  infection.  Several  varieties  of  pseudo-abscesses  may  be  present. 
In  some  cases  one  area  may  be  found  to  have  undergone  suppuration, 
while  in  others  the  mixed  infection  and  the  formation  of  pus  have  not  yet 
taken  place.  The  clinical  symptoms  are  severe  and  the  prognosis,  either 
for  surgical  or  medical  treatment,  unfavorable.  Fortunately  this  variety 
is  not  frequent.  Owing  to  the  character  of  his  material,  ,\Yunderlich's 
figures  regarding  suppurative  tuberculous  peritonitis  are  unusually  high. 
Ten  per  cent  of  his  cases  were  of  the  suppurative  variety.  Hamman  6 
saw  5  cases  in  his  series  of  103  subjects,  all  of  which  were  operated  upon 
or  came  to  postmortem.  As  the  advantages  of  operative  intervention 
have  become  more  recognized,  this  form  of  peritonitis  has  become  less 
frequent. 

Latent  Variety. — Under  this  heading  Bryant 15  describes  those 
cases  which  are  discovered  accidentally.     Stone  3  reports  several  instances 


332        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

of  deaths  among  patients  apparently  in  perfect  health  and  upon  whom 
postmortem  showed  advanced  tuberculous  peritonitis.  This  variety  is 
more  frequent  among  men. 

Frequency  of  Tuberculous  Peritonitis. — The  tubercle  bacillus 
is  the  most  frequent  etiological  factor  in  the  production  of  the  chronic 
form  of  peritonitis.  The  frequency  of  the  disease  in  men  and  women 
varies  considerably.  Operative  statistics  show  that  women  are  twice  to 
four  times  as  frequently  attacked  as  men,  but  curiously  enough  post- 
mortem statistics  show  men  more  often  affected  than  women.  An  ex- 
planation of  this  is  said  to  lie  in  the  fact  that  women  are  more  frequently 
subjected  to  operation  than  are  men.  Tuberculous  peritonitis  is  frequent 
among  children.  Cummins,  in  3,405  postmortems,  found  92  (2.7  per 
cent)  cases  of  tuberculous  peritonitis.  From  similar  material  Grawitz 
and  Bruin  (quoted  by  C.  H.  Mayo13)  observed  184  cases  among  13,992 
necropsies.  Among  5,687  intraperitoneal  operations  performed  in  the 
Mayo  clinic,  184  (3  per  cent)  were  for  some  variety  of  tuberculosis. 
Hartel  (quoted  by  Behle20)  found  tuberculous  peritonitis  in  3-5  per 
cent  of  27,000  postmortems,  Friedrich  (quoted  by  Behle20)  in  1.9  per 
cent.  Schlimpert,4  among  2,173  postmortems  upon  tuberculous  subjects, 
found  the  peritoneum  involved  in  4.9  per  cent.  Albrecht  (quoted  by 
Behle,20),  in  2,155  necropsies  upon  tuberculous  subjects,  found  peritonitis 
present  in  10  per  cent.  In  necropsies  upon  tuberculous  subjects  at  the 
Henry  Phipps  Institute,  peritoneal  involvement  was  found  present  in  2 
per  cent  of  subjects,  and  in  5.9  per  cent  of  all  females.  Nothnagel ia 
refers  to  statistics  varying  from  1.25  per  cent  to  others  as  high  as  16.16. 
The  latter  high  estimate  is  given  by  Borschke.5  Tuberculous  peritonitis 
is  frequent  in  the  young.  Thompson  21  found,  over  a  period  of  10  years, 
that  some  form  of  abdominal  tuberculosis  was  present  in  from  1.67  to 
4.51  per  cent  of  all  children  in  three  large  hospitals  in  the  United  King- 
dom. In  the  Mount  Sinai  Hospital  however  a  much  smaller  percentage 
was  encountered  (0.044  Per  cent),  while  in  the  same  period  of  years  in 
the  Edinburgh  Children's  Hospital  3.70  per  cent  was  observed.  Caird  22 
and  Bovaird  23  also  refer  to  the  frequency  among  children.  The  disease 
is  apparently  more  frequent  in  the  United  Kingdom  than  in  this  country. 
Faludi  24  has  collected  306  cases  which  occurred  in  patients  under  1 5 
years  of  age.  Of  these  nearly  one  half  occurred  between  yy  years  of 
age.     The  incidence  of  sexes  was  nearly  equal. 

Frequency  Among  the  Colored  Race. — Tuberculosis  in  general 
is  well  known  to  be  very  frequent  among  the  colored  race,  and  this 
variety  of  the  infection  is  no  exception.  Goodrich,12  Kelly,03  and  others 
have  referred  to  the  special  frequency  among  these  people,  some  authori- 


TUBERCULOSIS  OF  THE  PERITONEUM  333 

ties  believing  that  the  disease  is  twice  as  frequent  among  the  colored  as 
among  the  white. 

Variety  of  Bacillus  Causing  Tuberculous  Peritonitis. — Barker  25 
estimated  that  50  per  cent  of  tuberculous  peritonitis  was  due  to  bovine 
tuberculosis.  The  English  Commission  on  Tuberculosis  in  191 1  placed 
it  at  47  per  cent  and  the  German  Commission  at  63  per  cent.  It  has 
been  suggested  that  the  bovine  type  gives  a  more  favorable  prognosis 
than  the  human. 

Prognosis. — From  a  practical  viewpoint  the  majority  of  cases  of 
tuberculous  peritonitis  may  be  divided  into  two  groups,  the  one  in  which 
the  prognosis  is  fairly  good  if  the  proper  treatment  is  applied,  and  the 
other  in  which  the  prognosis  is  decidedly  less  favorable.  Mayo  -6  has 
emphasized  this  division.  The  first  group  comprises  those  cases  in  which 
a  definite  anatomic  starting  point  for  the  infection  can  be  demonstrated 
and  removed,  such  as  is  frequently  observed  in  women  when  the  fallopian 
tubes  are  plainly  the  primary  intraperitoneal  focus  for  the  infection.  The 
second  group  contains  those  cases  in  which  the  intraperitoneal  focus  of 
the  infection  is  less  well  defined  and  in  which,  although  a  considerable 
quantity  of  fluid  is  present,  it  is  contained  in  numerous  compartments, 
and  many  adhesions  have  been  formed.  The  character  of  the  fluid  is  to 
some  extent  also  a  guide,  the  clear  ascitic  fluid  being  the  most  favorable. 
Numerous  dense  adhesions,  the  presence  of  pus,  sinuses,  extensive  in- 
volvement of  the  entire  peritoneal  cavity,  high  fever,  poor  general  con- 
dition of  the  patient,  and  grave  primary  lesions,  such  as  extensive  pul- 
monary involvements,  are,  on  the  other  hand,  unfavorable. 

Symptoms. — As  has  been  stated,  these  depend  upon  the  stage  of  the 
disease  and  the  type  of  the  lesion,  and  in  some  cases  may  be  partially 
masked  by  the  symptoms  produced  by  the  primary  lesion.  The  disease 
occurs  in  women,  chiefly  in  the  child  bearing  period,  although  young  girls 
are  by  no  means  immune.  Alglave  (quoted  by  Jacobson27)  refers  to 
a  remarkable  case,  which  developed  in  an  infant  3  days  old.  Death 
occurred  on  the  sixth  day  and  necropsy  showed  an  advanced  general 
tuberculous  peritonitis.  In  a  few  cases  seen  by  the  author  the  disease 
has  followed  pregnancy  in  patients  the  incumbents  of  pulmonary  lesions. 
Kelly  63  has  noted  similar  occurrences.  A  history  of  trauma  is  present  in 
a  certain  proportion  of  cases,  but  is  a  greater  factor  among  men  than 
among  women. 

As  a  general  rule,  the  symptoms  are  those  of  a  chronic  peritonitis, 
which,  as  the  disease  advances,  are  associated  with  well  defined  loss  of 
strength,  loss  of  weight,  fever,  especially  in  the  evening,  rapid  pulse, 
increased  respiration,  and  nausea  or  vomiting.     Occasionally  an  acute 


334        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

onset  is  observed,  and  when  such  is  the  case,  the  infection  is  prone  to 
be  of  a  more  virulent  type.  The  local  symptoms  vary  widely ;  in  the 
common  ascitic  variety  the  presence  of  free  fluid  in  the  peritoneal  cavity 
with  its  accompanying  phenomena  are  the  chief  symptoms.  The  ascites 
generally  shows  a  more  or  less  marked  tendency  to  become  walled  off 
in  compartments.  This  is  especially  pronounced  as  the  disease  advances. 
Osier  has  drawn  attention  to  the  fact  that  some  cases  exhibit  a  subnormal 
temperature,  in  others  the  temperature  may  be  normal.  As  the  disease 
progresses  the  patients  become  pale  and  anemic.  The  amount  of  fluid 
which  may  be  present  varies  greatly  in  different  cases.  Nothnagel 19 
reports  a  case  in  which  11,500  c.cm.  were  removed.  The  amount  of 
fluid  occasionally  varies  in  amount  in  the  individual  case,  and  it  is  not 
uncommon  for  patients  themselves  to  remark  on  this  fact.  The  shape 
of  the  abdomen  is  often  somewhat  pyriform  in  tuberculous  peritonitis, 
rather  than  the  flattened  top  and  overlapping  sides  so  commonly  observed 
in  other  varieties  of  ascites.  The  fluid  is  generally  somewhat  yellowish, 
but  is  often  dark  from  the  admixture  of  blood.  It  may  be  clear  or  cloudy, 
or  contain  flakes  of  lymph  or  fibrin.  In  some  instances  it  is  milky  and 
opaque.  If  sacculated,  a  different  appearance  of  the  fluid  is  often  present 
in  the  different  loculi,  the  contents  of  some  being  clear  and  straw  colored, 
of  others  discolored.  This  difference  in  the  character  of  the  fluid  is 
doubtless  due  to  the  stage  of  the  disease  in  different  compartments,  to 
mixed  infection,  and  to  some  extent  to  the  parts  involved.  Ross  28  be- 
lieves a  high  percentage  of  lymphocytes  in  the  ascitic  fluid  suggestive 
of  tuberculosis,  and  an  excess  of  endothelial  cells,  except  in  the  very 
early  stages,  the  reverse.  Gibbert  and  Villaret 29  have  expressed  a 
similar  opinion  regarding  the  significance  of  numerous  endothelial  cells 
in  the  fluid.  Old  fluid  is  said  to  lose  its  bactericidal  properties,  and 
newly  formed  fluid  to  contain  greater  antituberculosis  action.  Edebohls 
attached  considerable  diagnostic  significance  to  the  occurrence  of  rounded 
plaque-like  thickenings  which  are  occasionally  palpable  on  the  anterior 
and  lateral  parenteral  peritoneum.  These  vary  from  1  to  8  cm.  in  di- 
ameter and  feel  not  unlike  urticarial  wheals.  They  occur  early  in  the 
course  of  the  disease.  Murphy  30  believed  these  to  be  hyperemic  in 
origin.  In  the  fibroplastic  type  the  formation  of  one  or  more  tumor- 
like masses  is  the  prominent  symptom.  These  masses  are  at  first  some- 
what movable,  but  later  tend  to  become  fixed.  The  masses  are  tender. 
When  suppuration  is  present  the  general  symptoms,  such  as  fever,  pain, 
and  tenderness,  are  more  marked.  Pain  is  however  a  variable  symptom, 
and  is  less  pronounced  in  tuberculous  than  in  other  forms  of  peritonitis, 
and  in  some  cases  it  may  be  entirely  absent.     More  or  less  pain  is, 


TUBERCULOSIS  OF  THE  PERITONEUM  335 

however,  usually  present.  It  must  be  remembered,  also,  that  tuberculous 
peritonitis  exhibits  a  tendency  towards  remissions  and  may  become 
quiescent  for  prolonged  periods,  even  without  treatment  of  any  kind, 
and,  in  a  small  percentage'  of  cases,  may  undergo  spontaneous  cure. 

Diarrhea,  or  alternate  diarrhea  and  constipation,  is  present  in  many 
cases,  especially  if  there  are  well  defined  intestinal  lesions.  For  this 
reason,  these  cases  are  sometimes  diagnosed  as  "intestinal  indigestion." 
The  spleen  is  frequently  enlarged,  but  its  demonstration  is  generally 
difficult.  The  liver  may  be  enlarged,  but  is  more  often  unchanged. 
The  skin  of  the  abdomen  is  tense,  waxy,  and  enlarged  veins  are  often 
present;  pigmentation  may  occur,  and  is  especially  likely  to  be  present 
on  the  face.  This  pigmentation  may  be  so  marked  as  to  suggest  Addi- 
son's disease  (Osier,16  p.  311).  In  women,  in  addition  to  a  history 
pointing  towards  a  bilateral  salpingitis,  scanty  menstruation  is  often 
present.  In  Hamman's  6  series  of  150  cases,  104  had  pain,  42  vomiting, 
48  constipation,  33  diarrhea,  4  alternating  diarrhea  and  constipation,  6 
blood  in  the  stools,  1 1  pain  in  the  chest,  47  coughs,  34  showed  physical 
evidence  of  pulmonary  tuberculosis,  and  in  30  cases  dyspnea  was  present, 
loss  of  weight  in  61,  night  sweats  in  27.  The  leukocyte  count  showed 
8  cases  under  5,000,  38  cases  between  5,000  and  10,000,  8  cases  between 
10,000  and  15,000,  8  cases  between  15,000  and  20,000,  and  3  cases  above 
20,000;  70  per  cent  were  under  10,000  and  83  per  cent  under  15,000. 
Stone 3  has  recorded  very  similar  blood  findings.  When  a  higher 
leukocyte  count  than  15,000  is  present,  it  usually  indicates  that  com- 
plications are  present.  Jaundice,  due  to  obstruction  of  the  ducts,  is  not 
uncommon.  Individual  tubercles  tend  to  become  encapsulated  by  con- 
nective tissue,  which  contracts  and  then  produces  a  cure.  The  connective 
tissue  growth  is  said  to  be  more  rapid  than  is  that  of  the  tubercle.  If 
in  a  given  case  this  be  true,  a  clinical  cure  results.  This  fibrous  meta- 
morphosis may  be  often  observed  in  histologic  preparations,  or  even 
macroscopically  at  operation,  or  on  the  postmortem  table.  Connective 
tissue  formation  may  result  in  partial  or  complete  intestinal  obstruction, 
or  in  dragging  and  distortion  of  the  various  intraperitoneal  viscera,  with 
resulting  clinical  symptoms.  Adhesions  may  result  from  fibrous  change 
in  the  tubercles  but  are  probably  more  often  due  to  an  ordinary  inflam- 
matory process. 

Diagnosis. — Many  cases  present  a  history  or  physical  signs  sug- 
gestive of  the  primary  infection  either  in  the  lungs  or  elsewhere.  Pleurisy 
as  an  accompaniment  of  tuberculous  peritonitis  has  been  observed  in 
some  cases,  and  a  previous  history  of  an  old  pleuritic  infection  is  fre- 
quently present.     A  bilateral  pleurisy  is  particularly  suggestive.     Peri- 


336        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

cardial  effusion  may  be  present,  but  is  infrequent  among  the  cases  ob- 
served by  the  author.  In  women  a  previous  history  indicating 
a  chronic  bilateral  salpingitis  is  often  obtainable.  In  a  smaller  percentage 
of  cases  a  previous  history  pointing  towards  the  appendix  or  cecum  will 
be  discovered,  and  in  rare  instances  the  upper  abdomen  will  have  been 
the  seat  of  the  primary  intraperitoneal  focus.  This  however  is  rare,  and 
in  the  great  majority  of  cases  the  fallopian  tubes  will  have  been  the 
primary  intraperitoneal  seat.  It  should  be  remembered  that  in  children 
the  mesenteric  glands  are  usually  the  primary  intraperitoneal  focus. 

As  a  general  rule  the  diagnosis  of  tuberculous  peritonitis  presents 
no  great  difficulties.  The  chronic  character  of  the  peritonitis,  the  loss 
of  weight  and  strength,  the  presence  of  either  pus  or  encapsulated  fluid 
Avithin  the  peritoneal  cavity,  the  tender  masses  especially  in  all  but  the 
miliary  and  ascitic  forms,  the  occasional  diarrhea  or  diarrhea  alternating 
with  constipation  in  those  cases  in  which  the  intestines  are  involved,  the 
resistance  of  palliative  treatment,  the  physical  findings,  and  the  previous 
history,  usually  render  the  diagnosis  easy.  An  inflammatory  mass  in 
the  pelvis  followed  by  ascitis  is  very  suggestive  of  tuberculous  peri- 
tonitis, and  is  the  condition  present  in  many  cases  of  tuberculous  peri- 
tonitis in  the  female.  Beale  31  has  directed  attention  to  the  fact  that 
the  pain  of  tuberculous  peritonitis  is  often  relieved  by  pressure.  This 
however  is  by  no  means  true  in  all  cases.  The  author  has  observed 
patients  in  whom  there  was  no  pain  except  on  pressure.  Monro  32  and 
others  have  referred  to  the  frequency  with  which  the  omentum  is  found 
rolled  up  as  a  nodular  transverse  cord  in  the  upper  abdomen.  This  is 
especially  common  in  the  fibroplastic  variety  of  the  disease.  This  pres- 
ence of  an  omental  tumor  is  very  characteristic  of  tuberculous  peritonitis, 
and  with  the  exception  of  pelvic  tumors  this  is  the  most  frequent  symp- 
tom. These  so-called  pseudo  tumors  are  however  generally  multiple. 
Cancer  and  cirrhosis  can  usually  be  easily  excluded,  as  can  pelvic  neo- 
plasms. Cirrhosis  of  the  liver  has  been  observed  in  conjunction  with 
tuberculous  peritonitis  by  Rolliston,  Osier,  and  others,  and  when  present, 
appears  to  markedly  reduce  the  resistant  power  of  the  peritoneum  to 
the  tuberculous  infection. 

From  a  general  carcinomatosis  of  the  peritoneum  tuberculosis  can 
be  differentiated  by  the  age  of  the  patient,  tuberculosis  occurring  early 
in  life  or  during  the  childhood  period,  and  carcinoma  generally  later. 
In  carcinoma  the  disease  is  steadily  progressive,  and  in  tuberculosis 
the  course  is  chronic.  Elevation  of  temperature,  pulse,  respiration, 
and  night  sweats  are  more  constant  in  tuberculosis  than  in  cancer. 
Cirrhosis  is  frequently  syphilitic  in  origin,  whereas  tuberculosis  gives 


TUBERCULOSIS  OF  THE  PERITONEUM  337 

p.  history  or  physical  signs  of  tuberculosis  elsewhere  in  the  body.  The 
physical  changes  in  the  liver  in  cirrhosis,  the  fact  that  cirrhosis  is  more 
frequent  in  men  and  is  comparatively  rare  in  early  life,  the  blood  picture, 
and  the  presence  or  absence  of  the  Wassermann  reaction  are  all  diag- 
nostic aids.  Cirrhosis  can  only  be  mistaken  for  the  ascitic  form  of 
tuberculosis,  and  its  differential  diagnosis  from  it  should  be  easy.  In 
cirrhosis  the  abdomen  usually  presents  the  well  known  saddle  bag  appear- 
ance, the  top  being  flat  and  the  sides  pouched  out.  In  tuberculous  peri- 
tonitis, on  the  other  hand,  a  pyriform  abdomen,  of  the  shape  often 
produced  by  a  greatly  overdistended  bladder,  or  by  an  ovarian  cyst,  is 
not  infrequently  met  with.  The  ascites  of  cirrhosis  is  generally  free 
and  few  adhesions  are  present,  whereas  in  tuberculosis  the  tendency  for 
the  fluid  to  become  walled  off  into  various  sized  compartments  is  pro- 
nounced, especially  as  the  disease  becomes  advanced.  As  a  result  of 
this,  movable  dullness  is  less  often  present. 

From  ovarian  neoplasms,  especially  those  producing  ascites  and  ad- 
hesions, the  diagnosis  may  be  more  difficult.  Ovarian  neoplasms  gen- 
erally occur  later  in  life,  and  there  is  an  absence  of  previous  history 
of  tuberculosis  elsewhere.  Ovarian  neoplasms,  unless  associated  with 
definite  inflammatory  lesions,  do  not  generally  produce  fever,  hyper- 
pyrexia, night  sweats,  or  intestinal  disturbances.  If  they  are  asso- 
ciated with  inflammatory  lesions,  there  is  generally  a  well  marked 
leukocytosis,  which  is  absent  in  tuberculosis.  The  ovarian  cyst,  even 
if  bound  down  by  adhesions  or  associated  with  ascites,  will  often  give 
a  history  of  a  previously  movable  pelvic  tumor  without  marked  evidence 
of  peritonitis;  whereas  the  tuberculosis,  even  if  it  has  been  preceded 
by  a  salpingitis,  will  usually  give  a  history  of  small  bilateral  inflammatory 
tumors  and  from  the  start  has  been  accompanied  by  pain,  tenderness, 
and  elevation  of  temperature.  In  some  cases  the  differential  diagnosis 
between  these  two  types  of  lesions  is  extremely  difficult.  A  careful  pelvic 
and  abdominal  examination  will,  however,  generally  clear  up  the  case. 

Occasionally,  when  seen  early  in  the  disease,  the  onset  may  simulate 
typhoid  fever.  As  a  rule,  the  tuberculosis  is  more  insidious  in  onset, 
and  in  any  case  the  differential  diagnosis  should  not  be  difficult.  The 
author  has  seen  two  cases  in  which  tuberculous  peritonitis  was  asso- 
ciated with  ovarian  neoplasms,  one  of  which  was  a  cystic  teratoma  and 
the  other  a  pseudomucinous  cyst.  In  both,  the  outer  surfaces  of  the 
tumors  were  studded  with  tubercles.  In  another  of  our  cases  the  tuber- 
culous peritonitis  was  associated  with  a  fibromyoma  of  the  uterus,  the 
tubes  being  tuberculous ;  in  another  case  a  cervical  carcinoma  was  present. 
Gallstones  were  found  in  still  another  case.     Croom  33  has  recorded  the 


338        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

history  of  a  remarkable  case  associated  with  extra-uterine  pregnancy, 
which  had  ruptured;  there  was  also  tuberculosis  of  the  kidney.  Tuber- 
culous peritonitis,  occurring  as  it  does  in  such  varying  forms,  may  be 
mistaken  for  many  of  the  intraperitoneal  diseases,  among  which  may 
be  mentioned  sarcoma,  omental  and  mesenteric  cysts,  renal  tuberculosis, 
ectopic  pregnancy,  various  diseases  of  the  gallbladder,  ulcer  and  cancer 
of  the  stomach,  duodenal  ulcer,  appendicitis,  ascites  due  to  cardiac  or 
renal  disease,  and  the  ascites  which  is  sometimes  present  as  an  accom- 
paniment of  the  infectious  diseases  of  childhood,  or  polyserositis.  Ex- 
cept in  extremely  atypical  cases,  the  differentiation  from  the  above  men- 
tioned conditions  should  not  be  difficult.  Thomayer  64  believes  that  in 
the  ascitic  variety  of  tuberculous  peritonitis  there  is  a  tendency  for 
tympany  to  be  more  pronounced  on  the  right  side  than  in  other  diseases 
producing  ascites,  except  cancer.  It  is  stated  that  this  is  the  case, 
because  in  tuberculous  peritonitis  the  mesentery  of  the  small  in- 
testines draws  them  to  the  right,  owing  to  their  oblique  insertion,  the 
space  thus  formed  on  the  left  becoming  filled  with  fluid.  Whereas  this 
sign  is  of  diagnostic  value,  the  reverse  may  be  the  case,  and  the  greatest 
tympany  present  on  the  left  side.  In  many  early  cases  observed  by  the 
author,  and  in  some  advanced  ones,  the  mesentery  has  not  been  markedly 
diseased  and  hence  has  not  undergone  contraction.  The  excretion  of 
large  quantities  of  indican,  which  is  so  characteristic  of  diffuse  acute 
peritonitis,  is  absent  in  the  tuberculous  form  of  the  disease.  (Noth- 
nagel.19) 

Pseudotuberculosis  of  the  peritoneum  is  a  rare  disease,  which,  from 
the  macroscopic  appearance  of  the  peritoneum,  may  be  similar  to  a  true 
tuberculosis,  and  in  some  recorded  cases  is  said  to  have  resembled  it 
to  some  extent  histologically.  The  etiology  of  this  condition  is  obscure. 
It  would  appear  in  many  cases  to  be  due  to  a  reaction  of  the  peritoneum 
to  foreign  bodies.  Ascites  is  rarely  present,  the  disease  usually  simu- 
lating the  fibro-adhesive  form  of  tuberculous  peritonitis.  The  foreign 
bodies  may  reach  the  peritoneum  through  rupture  of  cystic  neoplasms, 
hydatids,  or  rupture  of  some  portion  of  the  gastro-intestinal  tract. 
Cobb  34  has  recorded  the  history  of  a  case  due  to  vegetable  material. 
Alessandri 35  has  had  a  similar  case,  in  which  the  vegetable  residue 
gained  entrance  to  the  peritoneal  cavity  through  the  perforation  of  a 
gastric  ulcer.  Meyer  (quoted  by  Cobb34)  has  seen  a  case  due  to 
cholesterin  crystals  from  a  ruptured  ovarian  dermoid.  Hebbring 
(quoted  by  Cobb)  has  recorded  the  history  of  a  case  due  to  the  tenia 
worm,  which  gained  entrance  to  the  peritoneum  from  the  intestine. 
Egidi 36  has  recorded  the  histories  of  cases  of  pseudotuberculous  perito- 


TUBERCULOSIS  OF  THE  PERITONEUM  339 

nitis  which  have  healed  after  war  wounds  of  the  chest  and  abdomen. 
The  previous  history,  the  absence  of  tuberculosis  elsewhere  in  the  lxidy 
should  make  the  diagnosis  easy  in  most  cases. 

The  tuberculin  reaction  is  of  little  practical  value  in  the  diagnosis  of 
tuberculous  peritonitis  and  may  even  be  misleading.  In  some  cases 
animal  inoculations  may  be  of  value,  but  this  has  the  disadvantage  of 
requiring  considerable  time.  The  tubercle  bacilli  are  demonstrable 
by  staining  methods  in  the  ascitic  fluid  in  only  a  small  percentage 
of  cases,  and  even  animal  inoculation  is  not  certain.  Behle  20  states 
that  animal  inoculation  is  positive  in  only  50  per  cent  of  cases. 
Paracentesis  abdominis  is  more  dangerous  than  a  small  incision; 
if  the  latter  is  performed  the  diagnosis  can  nearly  always  be  made 
with  certainty,  and  if  any  doubt  exists,  the  excision  and  microscopic 
examination  of  a  small  piece  of  tissue  will  render  it  certain.  Animal 
inoculation  of  the  ground  up  diseased  tissue  will  give  positive  results 
in  practically  all  cases,  and  is  much  more  reliable  than  the  injection  of 
the  ascitic  fluid.  If  a  case  exists  in  which  the  diagnosis  is  in  doubt,  a 
small  incision  can  be  made,  under  local  anesthesia  if  necessary,  and  if 
the  condition  found  proves  to  be  one  in  which  operation  is  indicated, 
this  can  then  be  performed.  The  author  believes  this  a  far  preferable 
method  to  aspiration  with  a  needle.  With  the  present  improved  surgical 
technic,  paracentesis  abdominis  for  tuberculous  peritonitis  or  for  the 
diagnosis  of  vague  intraperitoneal  lesions,  is  no  longer  justifiable.  It 
is  less  certain  and  more  dangerous.  Paracentesis  abdominis  is  not  only 
dangerous,  in  that  grave  injury  may  be  done  to  the  intraperitoneal 
viscera,  but  it  is  unreliable.  Even  if  fluid  is  obtained  and  negative 
results  obtained  by  both  staining  and  by  the  time  consuming  inoculation 
methods,  tuberculosis  cannot  be  excluded  with  certainty.  Indeed,  open- 
ing the  abdomen  alone  is  not  a  certain  method  in  all  cases,  but  the  per- 
centage of  doubtful  cases  that  may  be  so  diagnosed  is  very  much  higher 
than  by  mere  puncture,  and  if  it  be  supplemented  by  histologic  examina- 
tion of  a  small  piece  of  excised  tissue  and  by  inoculation  of  the  ground 
up  particles  into  a  guinea  pig,  it  may  be  regarded  as  practically  certain. 
Morris  37  relates  the  history  of  an  instructive  case  exemplying  the  diffi- 
culties sometimes  encountered  in  differentiating  malignancy  from  tuber- 
culosis. He  performed  a  laparotomy  upon  a  patient,  and  on  opening  the 
abdomen  found  a  condition  closely  simulating  a  general  carcinomatosis. 
A  small  piece  of  tissue  was  excised,  the  abdomen  closed,  and  an  unfavor- 
able diagnosis  rendered.  A  complete  cure  followed,  which  the  patient 
attributed  to  Christian  Science,  which  had  been  employed  after  leaving 
the  hospital.     Through  a  mistake,  the  piece  of  tissue  excised  at  operation 


340        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

had  not  been  subjected  to  histologic  examination.  Subsequent  examina- 
tion of  this  showed  tuberculosis,  and  the  cure  was  consequently  due  to 
opening  the  abdomen.  But  it  is  doubtful  if  the  surgeon  received  credit 
for  the  cure. 

Treatment. — Whereas  a  definite  proportion  of  cases  of  tuberculous 
peritonitis  will  not  yield  to  either  surgical  or  medical  treatment,  and 
whereas  the  hygienic  and  medical  treatment  is  of  the  utmost  importance" 
and  should  not  be  minimized,  all  cases  of  tuberculous  peritonitis  are  essen- 
tially surgical,  and  the  final  decision  as  to  whether  or  not  to  operate 
upon  them  should  be  left  to  the  surgeon. 

In  arriving  at  a  decision  as  to  whether  or  not  to  operate  upon  any 
given  case,  many  points  must  be  considered  and  the  case  carefully  studied. 
Although  physical  examination  of  the  patient  to  determine  the  location 
and  condition  of  the  primary  lesion  is  of  the  first  importance,  two  other 
factors  besides  the  condition  of  the  peritoneal  lesion  must  be  borne  in 
mind,  the  first  that  a  certain  percentage  of  cases  will  recover  without 
operation,  and  the  second  that,  whereas  surgery  offers  the  best  hope 
of  a  cure  in  many  cases,  the  end  results  are,  even  at  best,  none  too 
satisfactory.  For  this  reason  a  conservative  attitude  should  be  adopted, 
and  in  the  majority  of  cases  a  preliminary  trial  of  palliative  measures 
is  the  wisest  course.  Some  surgeons  attempt  to  specify  definitely  how 
long  this  palliative  treatment  should  be  tried,  and  recommend  periods 
varying  from  2  to  8  weeks  and  even  longer.  All  cases  should  be  in- 
dividualized and  no  hard  and  fast  rule  adopted.  As  long  as  the  patient 
continues  to  improve,  operation  should  be  withheld.  Unfortunately 
there  are  many  cases  which  seem  to  arrive  at  a  standstill  or  get  definitely 
worse,  and  in  these  the  proper  decision  is  often  difficult  to  arrive  at. 
As  a  general  rule,  the  ascitic  variety  yields  definitely  better  results  by 
operation  and  the  removal  of  the  primary  intraperitoneal  focus,  than  by 
any  other  form  of  treatment.  Drainage  is  not  indicated,  and  often  leads 
to  fistulas  and  mixed  infection.  The  fibroplastic  form  is  decidedly  less 
favorable  and  must  be  judged  individually ;  in  those  cases  in  which  there 
are  great  numbers  of  adhesions,  much  thickening  of  the  peritoneum,  and 
extensive  involvement,  especially  if  sinuses  are  present,  the  operative 
prognosis  is  poor,  and  if  much  purulent  material  is  present,  is  decidedly 
unfavorable.  Haggard38  states  he  has  never  seen  a  recovery  of  such  a 
case.  The  miliary  variety  is  not  operable  under  any  circumstances,  as 
death  is  practically  certain  from  involvement  of  structures  other  than  the 
peritoneum. 

Simple  laparotomy  will  cure  a  certain  percentage  of  cases,  but  if 
the  primary  intraperitoneal  focus  can  be  removed,  this  percentage  will 


TUBERCULOSIS  OF  THE  PERITONEUM  341 

be  definitely  increased,  as  conclusively  proved  by  Mayo  29  and  others. 
It  must  be  remembered  that  tuberculous  peritonitis  is  frequent  in  the 
child  bearing  period  and  that,  as  tuberculous  salpingitis  is  generally 
bilateral,  the  removal  of  the  abdominal  focus  therefore  means  the  steril- 
ization of  the  patient.  Despite  this  fact,  bilateral  salpingectomy  un- 
doubtedly offers  the  best  hope  of  cure,  and  should  be  resorted  to  in 
most  cases.  The  fact  that  there  is  a  primary  focus  of  tuberculosis 
present  elsewhere,  often  in  the  lungs,  and  that  pregnancy  so  often  results 
disastrously  to  this  class  of  patients,  are  added  reasons  for  removing 
the  fallopian  tubes.  Tuberculous  peritonitis  is  generally  associated  with 
sterility.  Of  Baisch's  39  35  cases,  all  of  whom  were  in  the  child  bearing 
period,  only  1  became  pregnant  subsequently.  Tweedy 40  has  also  re- 
ferred to  the  frequency  of  sterility  in  these  cases.  The  appendix  and 
cecum  should  be  inspected,  and  as  a  rule  an  appendectomy  performed. 
The  fibroplastic  variety  of  tuberculous  peritonitis  is  especially  prone  to 
originate  from  the  iliocecal  region,  and  in  these  cases  the  removal  of 
this  part  of  the  bowel  is  indicated,  when  this  can  be  performed  without 
too  great  danger  to  the  patient. 

In  women,  however,  this  is  relatively  infrequently  the  case.  Except  in 
the  ascitic  variety,  a  cure  is  rarely  obtained,  unless  the  primary  focus  is 
removed,  and  even  in  that  variety  the  outlook  is  greatly  improved,  if  such 
an  operation  is  performed.  Mere  removal  of  the  fluid  may  cure  the 
ascitic  form,  as  the  old  ascitic  fluid  loses  its  bactericidal  properties. 
Even  if  fluid  reaccumulates  after  operation,  it  is  said  to  possess  a  higher 
opsonic  index  and  thus  a  higher  resistance  to  tuberculosis  than  the  old 
fluid.  The  admittance  of  air  to  the  peritoneal  cavity  has  been  suggested 
as  the  reason  for  cure  in  some  cases,  but  more  recent  study  tends  to  show 
that  it  is  the  removal  of  the  old  fluid  and  the  formation  of  new  which 
is  the  chief  beneficial  agent.  In  the  older  days,  the  late  Joseph  Price 
was  in  the  habit  of  referring  to  this  as  the  "sunshine  operation."  Other 
theories  which  have  been  from  time  to  time  advanced  to  explain  the  cures 
sometimes  following  simple  laparotomy  are  evacuation  of  toxins  in  the 
exudate,  hyperemia  produced  by  the  operation,  light  or  oxygen  intro- 
duced to  affected  area,  proliferation  caused  by  operation  resulting  in 
encapsulation  of  the  tubercles.  The  so  called  floating  theory  has  also 
been  advanced.  This  theory  is  based  upon  the  belief  that  the  infection 
originates  in  or  is  kept  up  by  the  escape  of  infectious  material  from 
the  abdominal  ends  of  the  patulous  fallopian  tubes,  and  that  these  re- 
main open  because  the  fimbria  are  floating  in  the  ascitic  fluid.  The  re- 
moval of  the  fluid  gives  the  tubes  a  chance  to  become  sealed  off  and  thus 
prevents  the  further  escape  of  the  infectious  material.     It  is  probable 


342        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

that  many  factors  enter  into  the  cure  of  these  cases.  Murphy  30  believed 
that  tuberculosis  of  the  fallopian  tubes  rarely,  if  ever,  caused  closure 
of  the  tubes,  unless  a  mixed  infection  was  present.  The  important 
point  which  has  been  amply  proven  is  that  a  definite  percentage  of  cases 
will  be  cured  by  simple  laparotomy,  and  a  still  greater  proportion,  if  it 
is  possible  to  remove  the  primary  intraperitoneal  focus  of  the  infection. 
Operation  offers  but  little  to  those  cases  in  which  there  a-re  numerous 
small  pockets  of  fluid,  much  fibrin,  and  many  adhesions,  and  will,  in  a 
certain  percentage  of  cases,  result  in  troublesome  fistulae.  Fortunately, 
according  to  Mayo,  the  adhesive  variety  is  the  most  favorable  for  a 
spontaneous  cure. 

Various  applications  to  the  peritoneum  have  been  suggested.  Judd  41 
recommends  hydrogen  peroxid,  followed  by  physiological  normal  salt 
solution.  He  further  suggests  that  the  hydrogen  peroxid  is  of  some 
diagnostic  aid,  in  that  it  produces  a  frosted  appearance  of  the  peri- 
toneum, and,  after  flushing  with  salt  solution,  the  tubercles  stand  out 
as  pearly  white  bodies.  Kocher 42  recommends  swabbing  tehe  cavities 
with  an  iodoform  and  glycerin  solution.  Stocker,43  as  a  result  of  animal 
experimentation,  recommends  the  application  of  the  tincture  of  iodin 
and  concludes  that  the  iodin  exerts  a  definite  curative  action  and  that  the 
danger  of  its  resulting  in  adhesions  has  been  overestimated.  Other 
investigators  have  employed  various  antiseptics. 

Strong  antiseptics  to  the  peritoneum  are  generally  contraindicated, 
and,  except  in  small,  walled  off  cavities,  are,  as  a  rule,  to  be  avoided. 
Probably  the  advantages  of  the  various  agents,  which  have  been  from 
time  to  time  advocated,  have  been  somewhat  overestimated  and  the  bene- 
ficial results  obtained  are  due  more  to  the  surgical  measures  instigated 
than  to  the  particular  form  of  application  employed.  The  use  of  radium 
or  X-ray  has  been  tried  in  these  cases.  Our  own  experience  has  been 
that  both  these  agents  will  very  definitely  cause  an  acute  exacerbation 
of  pelvic  peritonitis  in  chronic  cases,  whether  of  tuberculous  or  other 
origin,  and  in  some  instances  result  in  the  production  of  an  acute  general 
peritonitis.  Until  the  rationale  and  clinical  results  of  this  form  of  treat- 
ment have  been  more  thoroughly  established,  we  would  hesitate  to  employ 
either  of  these  agents  upon  the  class  of  cases  under  discussion. 

Hygienic  and  medicinal  treatment  is  of  the  utmost  importance.  In 
a  considerable  proportion  of  cases  such  a  course,  together  with  suitable 
palliative  treatment  directed  towards  the  peritonitis  itself  will  result 
in  a  cure  or  at  least  temporary  improvement.  A  reasonable  trial  of 
the  palliative  treatment  should  be  attempted,  but  should  not  be  con- 
tinued too  long.     Not  all  cases  are  operable,  but  it  is  a  poor  principle 


TUBERCULOSIS  OF  THE  PERITONEUM  343 

to  allow  what  was  a  comparatively  mild  case  to  be  converted  into  a  grave 
one.  Prior  to  the  more  generally  accepted  view  regarding  the  advisa- 
bility of  operation  in  many  of  these  cases,  it  was  not  uncommon  for  this 
to  occur,  and  even  today  there  is  a  tendency  for  the  surgeon  to  receive 
all  the  advanced  cases,  many  of  which  have  been  treated  for  prolonged 
periods  by  the  internist.  As  a  postoperative  measure,  hygiene  and 
medicinal  treatment  are,  if  anything,  of  even  greater  importance  than 
in  the  early  stages  of  the  disease.  An  attempt  should  be  made  to  place 
the  postoperative  patient  in  the  best  possible  surroundings.  Hartel 44 
recommends  sanatorium  treatment  when  possible.  A  suitable  climate, 
good  diet,  and  general  hygienic  treatment  will  greatly  increase  the  num- 
ber of  permanent  cures.  The  fact  must  not  be  lost  sight  of  that  many 
of  these  patients  have  more  or  less  definite  pulmonary  lesions,  and,  be- 
cause of  the  peritonitis,  they  are  below  par  and  therefore  especially 
subject  to  an  exacerbation  of  the  lung  condition.  As  a  general  rule  the 
postoperative  treatment  should  be  continued  for  a  prolonged  period ; 
even  after  patients  are  apparently  cured  they  should  be  urged  to  exercise 
proper  hygienic  measures,  and  should  be  kept  under  observation  for  at 
least  two  years.  Even  if  they  have  not  been  sterilized,  it  is  unwise  for 
women  to  become  pregnant  for  at  least  this  period  of  time,  and  in  many 
cases  it  is  better  for  the  patient  to  permanently  avoid  conception.  This, 
however,  is  a  point  on  which  each  case  must  be  judged  individually. 

Complications. — Operative. — What  has  been  said  in  a  previous 
chapter  regarding  anesthesia  and  operation  upon  tuberculous  patients 
should  be  considered.  Apart  from  the  danger  of  the  operation  or  anes- 
thetic lighting  up  preexisting,  although  perhaps  quiescent,  pulmonary 
lesions,  these  patients  possess  distinctly  lessened  resistance  and  bear 
operative  trauma  rather  poorly.  Owing  to  the  character  of  the  infection 
and  the  type  of  intraperitoneal  lesions  often  encountered,  fistulas  of 
various  kinds  are  especially  prone  to  follow  ill  advised  surgical  pro- 
cedures. For  this  reason  especial  care  should  be  adopted  in  dealing  with 
adhesions,  and  drainage  should  rarely  be  employed.  If  fistulas  result, 
they  are  extremely  likely  to  be  chronic  and  difficult  to  cure.  These 
patients  are  particularly  subject  to  wound  infection,  and  every  effort 
should  be  adopted  to  guard  against  this  complication.  Spencer  49  records 
the  history  of  an  unusual  complication,  which  occurred  in  a  girl  15  years 
of  age.  A  sinus  formed  which  communicated  with  an  intermittent 
hematosalpinx  and  for  one  year  blood  was  discharged  through  the  sinus 
at  each  menstrual  period.  The  condition  was  verified  by  operation.  The 
same  author  reports  the  history  of  another  case  in  a  girl  18  years  of 
age,   in  which  there  was  a  postoperative  fistula  through  which  blood 


344        GYXECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

appeared  at  each  menstrual  period  for  some  months  following  operation. 
Kaufmann46  has  recorded  the  history  of  cases  in  which  there  were 
several  small  utero-intestinal  fistulas,  and  numerous  instances  are  on 
record  in  which  fistulas  connecting  with  the  intestinal  tract  or  bladder 
have  been  present. 

Umbilical  fistulas  are  of  rare  occurrence,  but  are  less  infrequent  in 
tuberculous  than  in  any  other  form  of  peritonitis.  They  are  more  fre- 
quent in  children  than  in  adults,  and  in  the  latter,  when  associated  "with 
a  peritonitis,  are  almost  pathognomonic  of  tuberculosis.  Achard  and 
Leblanc  47  have  recently  reported  the  history  of  a  case. 

Tuberculosis  in  Hernia. — This  may  occur,  either  as  a  localized 
infection,  or  as  a  part  of  a  general  peritonitis.  Any  of  the  various  varie- 
ties may  be  present.  The  neck  and  bottom  of  the  sac  are  especially  subject 
to  attack.  It  is  more  common  in  men  and  in  children  than  in  women. 
When  starting  as  a  localized  infection  it  may  become  general.  It  usually 
produces  periodic  attacks  of  pain  and  is  rarely  diagnosed  prior  to  opera- 
tion. Cornet  48  was  probably  the  first  to*  report  a  case  of  tuberculosis 
in  a  hernial  sac.  Jonnesco,49  Hagler,50  and  Bruns  51  were  among  the 
earlier  observers  of  this  condition. 

Reformation  of  Ascites  Following  Operation* — Reaccumula- 
tion  of  fluid,  following  its  removal  by  operation,  occurs  in  certain  cases, 
but  is  less  likely  to  result,  if  the  primary  intraperitoneal  focus  for  in- 
fection is  removed,  than  otherwise.  Reaccumulation  of  fluid  is  not  a 
contraindication  to  operation  and  many  series  of  cases  have  been  recorded 
in  which  ultimate  cures  have  been  attained  only  after  repeated  operation. 
Mayo  26  has  recorded  an  instructive  series  of  such  cases,  some  of  which 
have  been  operated  upon  seven  times.  Schley,52  Murphy,30  D'Urso 
(quoted  by  Jacobson27),  and  others  have  reported  similar  experiences. 

Results. — -The  older  literature  is  replete  with  reports  comparing  the  re- 
sults of  medical  and  surgical  treatment  of  this  condition — the  advantages 
of  the  one  or  other  form  seeming  often  to  depend  on  whether  or  no  the 
given  series  of  cases  was  reported  by  an  internist  or  a  surgeon.  Kronig 
was  the  first  to  call  attention  to  the  value  of  simple  laparotomy,  and 
in  1890  reported  the  results  obtained  in  139  cases,  of  which  84  recovered. 
Shattuck,53  from  material  obtained  from  the  Massachusetts  General 
Hospital,  showed  a  mortality  of  68  per  cent  in  cases  treated  medically, 
as  compared  with  a  mortality  of  37.5  per  cent  among  patients  treated 
surgically.  Gelpke  54  has  recorded  the  results  in  a  series  of  71  operative 
cases,  in  which  there  were  4  deaths,  as  compared  with  a  series  of  51 
cases  treated  by  medical  methods  alone,  in  which  there  were  6  deaths. 
Some  important  statistics  have  been  collected  by  Bircher,55  who,  in  a 


TUBERCULOSIS  OF  THE  PERITONEUM  345 

series  of  1,295  cases  treated  surgically,  found  69  per  cent  of  immediate 
cures,  but  that  only  31  per  cent  were  well  a  year  or  more  after  operation. 
Wunderlich,17  among  176  cases  treated  surgically,  found  that  only  26 
per  cent  were  well  at  the  end  of  3  years.  It  must,  however,  l>e  taken 
into  consideration  that  practically  all  these  cases  were  the  incumbents 
of  a  primary  focus  elsewhere  than  in  the  peritoneum,  and  that  a  definite 
proportion  of  those  showing  poor  end  results  are  doubtless  due  to  this 
fact.  Fenzer  56  states  that  35  per  cent  are  now  cured  by  surgery,  which 
were  formally  fatal,  and  Moynihan57  presents  even  more  favorable 
figures.     Baisch,39  in  the  study  of  no  cases,  found  that  40  died  within 

4  years,  about  5/6  of  these  succumbed  in  the  first  year,  and  that  not 
one  died  after  the  fourth  year.     The  cases  studied  were  observed  from 

5  to  12  years.  These,  as  well  as  other  studies,  show  that  the  great  ma- 
jority of  fatal  cases  occurs  in  the  first  year  following  operation.  In 
Baisch's  series  there  were  22  cases  of  the  fibroplastic  variety;  of  these  1 1 
were  treated  medically  and  8  died ;  among  the  1 1  which  were  subjected  to 
operation,  there  were  3  postoperative  deaths,  while  5  of  the  remaining 

8  were  well  5  or  more  years  subsequently.  Goodrich  12  states  that  25 
per  cent  of  patients  recover,  if  treated  medically,  and  80  per  cent  if 
treated  surgically,  but  that  of  the  latter,  only  30  per.  cent  survive  a  5 
year  period,  25  per  cent  perishing  in  the  first  year.  Caird,22  in  31 
operative  cases,  observed  3  postoperative  deaths,   10  were  lost,  sight  of, 

9  died,  9  were  alive  for  periods  varying  from  2  to  9  years.  Mat- 
teson,10  in  a  series  of  53  cases  treated  surgically,  found  that  23  per  cent 
showed  no  improvement  and.  subsequently  died.  In  none  of  these  cases 
however  did  death  follow  immediately  after  operation,  nor  was  any 
directly  traceable  to  surgical  intervention.  Of  38  cases,  the  after  his- 
tories of  which  it  was  possible  to  trace,  44  per  cent  were  cured  of  the 
peritonitis.  Russanoff  reports  24  cases  treated  surgically,  of  which  9 
remained  well  from  2  to  5  years  after  operation.  Hartel,44  after  an  ex- 
tensive review  of  the  literature  and  an  analysis  of  the  end  results  obtained 
by  medical  and  surgical  treatment,  states  that  the  early  results  of  surgery 
are  better,  but  the  longer  the  periods  over  which  the  cases  are  followed, 
the  closer  do  the  surgical  results  come  to  those  obtained  by  medical  treat- 
ment only.  These  conclusions  are  probably  reached  because  of  the  fact 
that  not  a  few  of  the  cases  treated  surgically  subsequently  succumb, 
either  to  a  recurrence  -of  the  peritonitis,  or  to  some  other  form  of  tuber- 
culosis. In  this  connection  Ochsner 59  states  that  most  cases  are  first 
treated  medically,  and  when  finally  turned  over  to  the  surgeon,  are  in 
bad  condition,  and  his  50  per  cent  of  recoveries  is  in  the  worst  cases, 
whereas,  if  he  had  had  the  case  from  the  beginning,  his  percentage  of 


346        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

cures  would  be  75  per  cent  at  least.  Marckthurm  (quoted  by  Senn  and 
Friend  60)  records  36  cases  with  21  permanent  cures.  Rosch  (quoted,  by 
Senn  and  Friend  60)  records  358  cases  with  20  operative  deaths;  70  per 
cent  are  reported  as  cured.  Binnie  61  believes  30  per  cent  cured  and  25 
per  cent  improved  by  surgical  intervention.  Mayo  13  reports  conclusions 
based  upon  144  operative  cases  ;  59  were  operated  upon  by  the  older  meth- 
ods, 42  cured,  15  improved,  and  2  deaths;  in  58  cases  the  fallopian  tubes 
were  removed,  56  recoveries  and  2  deaths ;  in  27  the  vermiform  ap- 
pendix was  tuberculous  and  removed,  no  deaths.  Thus,  among  144 
operative  cases,  there  was  a  surgical  mortality  of  2.JJ  per  cent. 

The  prognosis  in  children,  especially  the  very  young,  is  less  favorable 
than  in  adults.  Dingwall-Fordyce,62  in  a  series  of  137  cases,  found  that 
in  the  majority  the  onset  was  prior  to  the  fourth  year,  the  earlier  the 
onset  the  more  severe  the  case  ;  the  mortality  in  this  series  was  46  per  cent 
among  the  bottle  fed  infants  and  28  per  cent  among  the  breast 
fed.     Free  fluid  was  uncommon  under  3  years  of  age. 

An  analysis  of  2356  cases  treated  surgically,  some  of  which  were  not 
subjected  to  modern  surgical  methods,  shows  that  there  were  39  per  cent 
of  permanent  cures.  A  more  careful  analysis,  which  includes  only  those 
cases  in  which  the  report  states  that  they  have  been  definitely  followed 
for  a  period  of  3  years  or  more,  shows  31  per  cent  of  permanent  cures. 
Another  30  per  cent  are  definitely  improved,  and  about  36  per  cent  die  of 
a  recurrence  of  the  peritonitis,  of  tuberculosis  elsewhere  in  the  body,  or 
from  intercurrent  disease  in  the  three  year  period  following  operation. 
The  Mayo  series  of  144  cases  treated  surgically  with  4  deaths  is  a  fair 
presentation  of  the  immediate  surgical  mortality  in  properly  selected  cases 
treated  by  modern  surgical  methods. 


LITERATURE 


2 

3 
4 

5 
6 

7 
8 

9 
10 


Wells,  Sir  S.     Ovarian  and  Uterine  Tumors.     London,  1873. 

Kronig.     Centrbl.  f.  Chir.     1890.     p.  657. 

Stone,  A.  K.     Bost.  Med.  Surg.  Jr.     1908.     158:705. 

Schlimpert.     Arch.  f.  Gyn.     191 1.     94:863. 

Borschke.     Virch.  Arch.     v.  127. 

Hamman,  L.     J.  Hopk.  Hosp.  Bui.     1908.     19:256. 

AI  Onsterman-n.     Inaug.  Dis.     Munich,  1890. 

Rokitansky.     Handbook  of  Pathological  Anatomy.     1855.  2:29. 

Albrecht.     Deutsch.  Kong,  of  Gyn.  u.  Obst.     191 1. 

Matteson,  G.  A.     Prov.  Med.  Jr.     191 1.     12:6. 


TUBERCULOSIS  OF  THE  PERITONEUM  347 

11.  Allshut,  W.     Tr.  6th  Intern.  Cong.  Tuberc.     1908. 

12.  Goodrich,  C.  H.     L.  I.  Med.  Jr.     1910.    4:414. 

13.  Mayo,  C.  H.  and  Mayo,  W  J.     A  Collection  of  Papers.     Phila- 

delphia and  London.     19 12.     p.  37,  45. 

14.  Kraus.     Monschr.  f.  Gebh.  u.  Gyn.     1902.     15:2. 

15.  Bryant,  J.  D.     Principles  of  Surgery.     Philadelphia  and  London. 

I9I3- 

16.  Osler,  Sir  W.     Principles  and  Practice  of  Medicine.     New  York 

and  London.     D.  Appleton  &  Co.     1905. 

17.  Wunderlich.    Arch.  f.  Klin.  Gyn.     1899.     59:216. 

18.  Baisch.     Munch.  Med.  Woch.     Aug.  20,  1907. 

19.  Nothnagel,   H.     Diseases  of  the  Intestines  and  Peritoneum  in 

"Encyclopedia  of  the  Practice  of  Medicine."     Philadelphia  and 
New  York.     1907. 

20.  Behle,  A.  C.     North  West  Med.     1914.     Vol.  vi.  No.  1,  p.  16. 

21.  Thompson.     Brit.  Jr.  Tuberc.     1907.     1 :25c. 

22.  Caird,  T.  M.     Edinb.  Med.  Jr.     1912.     1 :29s. 
2T,.     Bovaird,  D.     Arch.  Ped.     1909.     26  432. 

24.  Faludi.     Jhrb.  f .  Kindlik.     1905.     62 :304. 

25.  Barker,  L.  F.     In  Monographic  Medicine.     New  York.     1916. 

D.  Appleton  &  Co.     3  :684. 

26.  Mayo,  W.  J.    Am.  Jr.  Med.  A.    April  15,  1905.     1918.     71  :6. 

27.  Jacobson,  N.     N.  Y.  St.  Jr.  Med.     191 1.     11:53. 

28.  Ross,  A.  E.    Tr.  London  Path.  Soc.     1906.     57:361. 

29.  Gibbert  et  Villard.     Compt.  rend.  soc.  de  biol.     1906.     60:820. 

30.  Murphy,  J.  B.     Tuberculosis  of  the  Female  Genitalia  and  Peri- 

toneum.    Chicago,   1903. 

31.  Beale,  P.     Med.  Press  and  Circ.     1909.     138:112. 

32.  Monro,  J.   C.     In  Keen's   Surgery.     Philadelphia,    1908,   W.   B. 

Saunders.    3 :748. 

33.  Croom,  J.  H.     Jr.  Obst.  Gyn.  Brit.  Emp.     1914.     26:192. 

34.  Cobb,  F.    Bost.  Med.  Surg.  Jr.     1907.     157:861. 

35.  Alessandri.     Policlin.     Aug.,  1908. 

36.  Egidi,  G.     Policlin.     1920.     2y,  No.  1. 

37.  Morris,  R.  J.     Arch.  Diag.     1914-     7:146. 

38.  Haggard,  W.  D.    Jr.  Tenn.  St.  Med.  A.     1909.     2:126. 

39.  Baisch.     Arch.  f.  Gyn.     1909.     84:345. 

40.  Tweedy,  E.  H.    Jr.  Obst.  Gyn.  Brit.  Emp.     1912.     22:342. 

41.  Judd,  A.    N.  Y.  Med.  Jr.     1911.    93:1222. 

42.  Kocher,  T.     A  Text  Book  of  Operative  Surgery.     London,  191 1. 

43.  Stocker,  S.     Schweiz.  Rundsch.  f.  Med.     1913.     13:745- 


348        GYNECOLOGICAL  AND  OBSTETRICAL  TUBERCULOSIS 

44.  Hartel,  F.     Ergebn.  d.  Chir.  u.  Orth.     1913.     6:370.     (Contains 

an  extensive  bibliography.) 

45.  Spencer,  W.  G.     Brit  Med.  Jr.    Jan..  10,  1914. 

46.  Kaufmann.     Arch.  f.  Gyn.     1887.     29:407. 

47.  Achard,  C.,  et  Lebdanc,  A.     Bui.  et  mem.  soc.  med.  des  hop. 

de  Paris.     1918.     42:301. 

48.  Cornet,  G.    Tuberculosis.     Philadelphia,  New  York,  and  London. 

1904.     p.    194. 

49.  Jonnesco.     Rev.  de  chir.     1891.     11:185. 

50.  Hager.     Arch.  f.  Chir.     1893.     15:316. 

51.  Bruns,  P.     Bietr.  z.  Klin.  Chir.     1892.     9:209. 

52.  Schley.     N.  Y.  Med.  Rec.     19*12.    81  493. 

53.  Shattuck.    Am.  Jr.  Med.  Sc.     1902.     124:1. 

54.  Gelpke.     Deutsch.  Ztschr.  f.  Chir.     84:512. 

55.  Bircher,    E.      Die   Chronische   Bauchfell   Tuberkulose,    ihre   Be- 

handlung  mit  Rontgenstrahlen.     Aarau,  1907,  Sauerlander. 

56.  Fenzer.     Ann.  Surg.     Dec,  1901. 

57.  Moynihan,  Sir  Bi     Surgical  Operations:     1905.     p.  89. 

58.  Russanoff,  A.  G.     Dissertation.     Moscow,  19 13.      (Contains  an 

extensive  bibliography. ) 

59.  Ochsner,  A.  J\     Tr.  Am.  Surg.  A.     1902.     20:191. 

60.  Senn,  E.  J.,  and' Friend,  L.    Principles  of  Surgery.    Philadelphia, 

1909.     p.  546. 

61.  Binnie,  J.  F.     Manual  of  Operative  Surgery.     Philadelphia,  1913. 

P-  438- 

62.  Dingwall-Fordyce,  A.     B;rit.  Med.  Jr.     1909.     p.  761. 

63.  Kelly,  H.  A.     Operative  Gynecology.     1914. 


INDEX 


Abortion,  Indication  for,  in  the  tuber- 
culous, 265 

—  result  of,  266 

—  technic,  271 

Abscess  of  the  ovary,  195 

Acid     proof     bacteria,     differentiation 

from  tubercle  bacillus,  10 
Adenitis,  external  genitalia,  113 

—  with  vaginitis,  142 
Adenofibroma,     with     tuberculosis     of 

breast,  318 
Adenomyoma     and    tuberculosis,    227, 

228 
Adnexitis — See  Salpingitis 
Age  of  menopause  in  the  tuberculous, 

293 
Amenorrhea,  291,  293 

—  in  pulmonary  tuberculosis,  284 
Anesthesia   and   pulmonary   tuberculo- 
sis, 300 

—  choice  of,  302,  303 

—  classification   of   pulmonary   lesions, 

301 

—  importance     of    expert    anesthetist, 

304 

—  precautions,  303 

—  salpingitis,  215 

—  spinal,  303 

Animals,  congenital  tuberculosis  in,  58 
Appendicitis  and  tuberculosis,  240 
Ascites,  334 

—  character  in  peritonitis,  334 

—  general  peritonitis,  329 

—  reformation  after  operation,  344 

Bacillemia,  tuberculous,  51 
Bacillus  leprae,  10 

—  differentiation    from    tubercle   bacil- 

lus, 10 
Bartholin's  gland,  tuberculosis  of,  121. 

See  External  Genitalia 
Bartholinitis,  121 
Biopsy — cervix,  6 

—  external  genitalia,  6 

—  vagina,  6 


Benign  tumor  and  tuberculosis,  226 
Bladder,  rupture  pyosalpinx  into,  235 
Blood  picture  in  peritonitis,  335 
Body  of  uterus,  tuberculosis  of,  182 
Bone  tuberculous  and  pregnancy,  279 
Bowel,  rupture  pyosalpinx  into,  235 
Breast,  tuberculosis  of,  312 

—  age,  312 

—  bilateral,  317 

—  biopsy   and   other   diagnostic   meth- 

ods, 319 

—  cold  abscess  of,  314 

—  confluent  variety,  314 

—  course  of  disease,  317 

—  diagnosis,  318 

—  disseminated  variety,  315 

—  end  results,  320 

—  frequency,  309 

—  frequency  of  fistula,  318 

—  general   condition,  317 

—  historic,  309,  312 

—  in  male,  309 

—  obliterative  mastitis,  315 

—  predisposing  causes,  312 

—  primary  and  secondary,  310 

—  routes  of  infection,  311 

—  sclerosing    variety,    315 

— ■  similarity  to  true  neoplasm,  316 

—  symptoms,  316 

—  treatment,  319 

—  with  true  neoplasms,  318 

—  varieties,  314 

Cancer  and  tuberculosis,  224,  225, 
228,  318 

Carcinoma  and  tuberculosis,  224,  225, 
228,  318 

Carcinoma  differentiated  from  cervici- 
tis, 157 

Caseous  indometritis,  183 

Cervicitis,   152 

—  age,  152 

—  biopsy,  6 

—  carcinoma,  228 

—  case  histories,  160 


349 


350 


INDEX 


Cervicitis,  diagnosis,  156 

—  differential,   158 

—  differentiation  from  carcinoma,  157 

—  discharge,    153 
■ —  frequency,    149 

—  hemorrhage,    153 

—  histologic  simulating  carcinoma,  22 

—  historic,  149 

—  interstitial,  156 

—  interstitial,  pathology,  21 

—  location  of  primary  focus,  151 

—  miliary,   156 

—  miliary,  pathology,  22 

—  other  portions  of  the   genital  tract 

involved  with,  150 

—  pain,  153 

—  papillary,  155 

—  papillary,  pathology,  21 

—  pathology,  20 

—  phthisis   with,   151 

—  portion  of  cervix  involved,  154 

—  predisposing  causes,  151 

—  primary,  150,  151 

—  prognosis,  158 

—  pseudo  neoplasms,  227 

—  salpingitis  with,   150 

secondary  infliction,   150 

symptoms,   152 

treatment,  1 59 

ulcerative,  155 

ulcerative,  pathology,  20 

varieties,  154 

—  with  endometritis,  150 
Cervix,  149.     See  Cervicitis 
Cesarean    section    in    the    tuberculous, 

276 
Coitus,  infection  by,  97,  98,  99 
Colored  race,  susceptibility,  331 
Complications,  peritonitis,  343 
Confluent  mastitis,  314 
Congenital  tuberculosis,  44,  251,  277 

—  animal  experiments,  59 

—  case  histories,  64 

—  definition,  45 

—  etiology,  46 

—  experimental   criticism,   60 

—  fate  of  the  congenitally  infected,  63 

—  frequency,  55 

—  germinative,  49 

—  germinative   spermatozoic,  46 

—  histology  of  placenta  in  relation  to, 

51 

—  historic,  45,  58 


Congenital  tuberculosis,  in  animals,  58 

—  literature,  87 

—  period  in  which  transmission  is  most 

likely  to  occur,  61 

—  predisposing  factors,  62 

—  summary,  85 

—  unfertilized  ovum,  4 
Convalescence  in  the  tuberculous,  305 
Corporeal    endometritis,    See   Endome- 
tritis 

Corpus   uteri,    182 

—  tuberculosis,   182 
Curettage,  6 

—  diagnostic,  6 

in  endometritis,  7 

Cystadenoma  and  tuberculosis,  227 
Cystitis  with  salpingitis,  192.    See  Sal- 
pingitis 

—  and  pregnancy,  279 

Decidua,  See  Deciduitis 
Deciduitis,  30 

Diagnosis  by  staining  method  employ- 
ing exudate,  11 

—  cervicitis,   156 

—  differential,  pelvic  inflammatory  dis- 

ease, 207 

—  endometritis,  186 

—  external  genitalia,  115 

—  histologic  summary,   12 

—  laboratory  methods,  summary,  12 

—  pelvic  inflammatory  disease,  204 

—  pelvic  peritonitis,  204 

—  salpingitis,  204 

—  tuberculin  in,  11 

—  tuberculin  in  salpingitis,  206 

—  vaginitis,  143 
Diagnostic  curettage,  6 
Diagnostic  excision,  6 

lower  genital  tract,  6 

Discharge,  6 

—  examination  of,  for  diagnosis,  6 
Dissemination  from  genital  lesions,  237 
Disseminated  mastitis,  315 
Drainage,  in  the  treatment  of  salping- 
itis, 220 

Dysmenorrhea,  185 

—  in  pulmonary  tuberculosis,  284,  289 

—  treatment,  290 
Dyspareunia  in  vaginitis,  142 

Eclampsia,  279 

—  tuberculosis,  279 


INDEX 


35i 


Endometritis,  182 

—  caseous,  183 

—  cervicitis  with,  150 

—  diagnostis  curettage,  7 

—  diagnostic    examination    of    leucor- 

rhea,  7 

—  diagnosis,   185 

—  frequency,   182 

—  miliary,  183 

—  pathology,  23 

—  symptoms,   184 

—  treatment,   185 

—  ulcerative,  183 

—  varieties,   183 

—  varieties,  pathology,  23 
Ether,  See  Anesthesia 
Etiology,  109 

—  external  genitalia,  109 

—  menstrual    disturbances    in    pulmo- 

nary tuberculosis,  285 

Examination  of  discharge  for  diagno- 
sis, 6 

Excision,  diagnostic,  See  Biopsy 

—  diagnostic,  lower  genital  tract,  6 
Experimental    congenital    tuberculosis, 

59 
External  genitalia,  108 

—  adenitis,  113 

—  age,  111 

—  biopsy,  6 

—  case  histories,  119 

—  diagnosis,  17,  115 

—  etiology,  109 

—  frequency,  108 

—  frequency  of  primary,   108 

—  frequency  of  secondary,  108 

—  genitalia,  109 

—  historic,  108 

—  hypertrophic,  109,  114 

—  hypertrophic  variety,   pathology,   17 

—  modes  of  infection,  111 

—  parts  most  frequently  involved,  114 

—  pathology,  15 

—  prognosis,  115 

—  pruritis,  113 

—  pseudoneoplasms,  227 

—  symptoms,    109 

—  trauma  as  predisposing  cause,  109 

—  treatment,  116 

—  ulcerative,  109,  113 

—  varieties,  15,  109 

Fertility  in  pulmonary  tuberculosis,  244 


Fetal  tuberculosis,  50 
Fetus,  susceptibility,  50 

—  tubercle    bacillus    in,    without   histo- 

logic change,  case  reports,  81 
Fever  during  menses,  295 
Fibroplastic   general   peritonitis,   330 
Fistula    following   operative    treatment 

of  salpingitis,  220 

—  following  operative   treatment,  gen- 

eral peritonitis,  343 
Frequency,  of  genital  tuberculosis,  103 

—  external  genitalia,  108 

—  of  pregnancy  and  tuberculosis,  244 

—  of  primary   lesions   producing   geni- 

tal tuberculosis,  105 

General  peritonitis,  See  Peritonitis 

—  ascites,  334 

—  ascites  following  operation,  344 

—  blood  picture,  335 

—  character,  334 

—  character  of  fluid  in,  334 

—  complications,  operative,  343 

—  diagnosis,   335 

—  differential  diagnosis,  336 

—  fistula  following  operation,  343 

—  frequency,  332 

—  hernia,  344 

—  in  children,  332 

—  in  the  colored  race,  331 

—  latent  variety,  331 

—  mortality,   344 

—  paracentesis,   339 

—  peritonitis,  344 

—  prognosis,  333 

—  pseudotuberculous  peritonitis,  337 

—  pseudo-tumors  in,  336 

—  reformation  ascites  after  operation, 

344 

—  results,  medical  treatment,  344 

—  results,  surgical  treatment,  344 

—  symptoms,  333 

—  treatment,  340 

—  treatment,  medical.  340 

—  treatment,  surgical.  340 

—  variety     tubercle     bacillus     causing, 

333 
Genital,  historic,  3 
Genital  infection,  95 

—  primary,  95 

—  routes  of,  95 

Genital  lesions  and  pregnancy,  279 
Genital  tuberculosis,  pregnancy,  103 


352 


INDEX 


Genococcal  salpingitis,  207 

—  differential  diagnosis   207 

Hemoptysis,  295 

—  periodic,  295 

Hemorrhage  due  to  cervicitis,  153 
Hernia,  237 

—  tuberculosis  in,  237 

—  tuberculous  peritonitis,  344 
Histologic    methods,    diagnosis,    sum- 
mary, 12 

— 'ulcerative   form,  tuberculosis  of  the 

external  genitalia,  17 
Histology    of    placenta    in    relation    to 

congenital  tuberculosis,  51 
Historic,  p.  — 

—  breast,  tuberculosis  of,  309 

—  cervicitis,    149 

—  congenital  tuberculosis,  45,  58 

—  external  genitalia,  108 

—  general,  1 

—  general  peritonitis,  323 

—  genital,  3 
Historic,  249 

—  lactation  in  the  tuberculous,  249 

—  menorrhagia     in     the     tuberculous, 

294 

—  pregnancy  and  tuberculosis,  243 

—  tubercle  bacilli  in  decidua,  58 

—  vaginitis,  140 
Hydrosalpinx,  39,  See  Salpingitis 

—  pathology7,  39 

torsion,  231 

Hyperexia  during  menses,  295 
Hypertrophic  forms,  external  genitalia, 

pathology,   17 
Hypertrophic   external   genitalia,   109 

—  vaginal,  19,  142 

—  variety,  external  genitalia,  114 

—  variety,    external    genitalia,    pathol- 

ogy, 17 
Hypoplasia  and  tuberculosis,  287 
Hysterotomy,   pregnancy  and  tubercu- 
losis, 272 

Infection,   autogenital,  95 
Infection,  marital,  261 

—  predisposing  causes,  103 

—  primary,   experimental,  99 

—  primary  genital,  95 

—  routes  of  genital,  95 

—  routes  of,  summary,  102 

—  secondary,  101 


Infection,  secondary  frequency  of  pri- 
mary foci,   105 
Interstitial  cervicitis,   156 
Intramural  abscess,  27 

—  pathology,  27 

—  recorded  cases,  27 

Laboratory  methods  of  diagnosis,  sum- 
mary, 12 
Latent  general  peritonitis,  331 
Leukorrhea,  184 

—  demonstration  of  tubercle  bacillus  in, 

11 

—  diagnostic  examination  of,  7 

—  due  to  cervicitis,  153 

—  in  pulmonary  tuberculosis,  295 

—  tubercle  bacilli  in,  184 
Local  anesthesia,  See  Anesthesia 

Mammary       tuberculosis       (also       se;± 

Breast,  tuberculosis  of),  309 
Marital   infection,  261 
Marriage,  law  regarding,  261 

—  of  tuberculous  women,  261 
Mastitis   (also  see  Breast,  tuberculosis 

of),  309 
Menopause,  293 

—  age  of,  in  the  tuberculous,  293 

—  in  the  tuberculous,  288 
Menorrhagia   in  pulmonary  tuberculo- 
sis, 284,  293 

—  treatment,  294 

Menstrual  disturbances  and  pulmo- 
nary tuberculosis,  284 

Menstruation,  influence  on  tempera- 
ture, 295 

—  etiology,  285 

—  frequency,   284 
Miliary  cervicitis,  156 

—  endometritis,    183 

—  peritonitis,   acute,   329 

—  vaginitis,  142 

—  vaginitis,  pathology,  143 
Mortality,  pelvic  inflammatory  disease, 

211 

—  salpingitis,  211 

Myoma  and  tuberculosis,  228 
Myometritis,  182 

—  pathology,  26 

Neoplasms,  benign  and  tuberculous, 
226 

—  differentiation  from  cervicitis,  157 


INDEX 


353 


Neoplasms  and  tuberculosis,  224,  318 
New    growths,    benign    and    malignant 

tuberculosis,  224,  318 
Nitrous  oxide,  See  Anesthesia 

Obliterative  mastitis,  315 
Oophoritis,  192 

—  pathology,  41 

Operative  treatment,  salpingitis,  218 
Operation  and  pulmonary  tuberculosis, 
305 

—  anesthesia,  300 

anesthesia,  chloroform,  305 

anesthesia,  choice  of,  302,  303 

anesthesia,  ether,  303 

anesthesia,  local,  302 

anesthesia,  mixtures,  303 

— ■  —  anesthesia,  nitrous  oxide,  303 

anesthesia,  precaution,  303 

anesthesia,  spinal,  303 

convalescence,   305 

importance  of  expert  anesthetists, 

304 

precautions,    303 

results,  305 

with    complication    of    pulmonary 

lesions,  301 
Organisms  likely  to  be  mistaken  for  the 

tubercle  bacillus,  8 
Osseous    tuberculosis    and    pregnancy, 

279 
Ovarian  abscess,  195 

—  pathology,  41 

—  tumors  and  tuberculosis,  227 

Palliative  treatment,   salpingitis,  216 

Papillary  cervicitis,  155 

Paracentesis    abdominis    in    peritonitis, 

339 
Pathology,  15 

—  adenitis,    inguinal    in    ulcerative    tu- 

berculosis of  the  external  genitalia, 
17 

—  cervix,  20 
histologic,  22 

histologic  picture  simulating  car- 
cinoma, 22 

interstitial  variety,  21 

papillary  variety,  21 

miliary  variety,  22 

ulcerative  variety,  20 

—  deciduitis,  30 

—  endometritis,  23 


Pathology,  endometritis,  caseous,  24 

miliary,   23 

varieties,   23 

—  external  genitalia,  15 

hypertrophic  variety,  17 

ulcerative  variety,  16 

—  general  peritonitis,  327 

—  hydrosalpinx,  39 

—  hypertrophic  variety,  vaginal,  19 
of  the  external  genitalia,  17 

—  intramural  abscess,  27 

—  miliary  vaginitis,  19 

—  myometritis,  26 

—  oophoritis,  41 

—  ovarian  abscess,  42 

—  perioophoritis,  41 
— ■  perisalpingitis,  35 

—  placental  tuberculosis,  31 

—  pyosalpinx,  38 

—  salpingitis,  34,  36 

histologically     suggesting     carci- 
noma, 40 
isthmica   nodosa,   36 

—  ulcerative  form  of  the  external  gen- 

italia, 16 

—  vaginitis,  18 

hypertrophic  form,  19 

ulcerative  variety,  18 

Pelvic   inflammatory  disease,   See   Pel- 
vic Peritonitis 
Pelvic  peritonitis,   192,   See  Salpingitis 

—  diagnosis,  204 

—  mortality,  211 

—  operative   treatment,   218 

—  prognosis,  209 

—  results   of  operative  treatment,  211, 

220 

—  treatment,  214 

Periappendicitis  and  salpingitis,  240 
Perimetritis,   182 

Perioophoritis,     192,     See     Salpingitis, 
also  Pelvic  Peritonitis 

pathology,  41 

Perisalpingitis, 

—  pathology,  35 
Peritonitis,   199 

secondary     form     genital     focus, 

237 
Peritonitis,  general,  344 

—  acute  miliary,  329 
ascitic,  329 

—  classification,  329 
fibro-plastic,  330 


354 


INDEX 


Peritonitis,   general,   classification,  his- 
toric, 323 

intraperitoneal  foci,  324 

mixed  infection,  328 

mode  of  development,  327 

—  pathology,  327 

primary  and  secondary,  324 

routes  of  infection,  325 

and  salpingitis,  326,  327 

suppurative  variety,  331 

Peritonitis,  pelvic,  192.    See  Salpingitis 

—  diagnosis,  204 
differential,  207 

—  mortality,  211 

—  operative  treatment,  218 

—  prognosis,  209 

—  results  of  operative  treatment,  211, 

220 

—  treatment,  214 
Peritonitis  and  hernia,  237,  344 

—  pregnancy,  279 
Placenta,   249 

—  histology    in    relation   to    congenital 

tuberculosis,  51 

—  tubercle   bacillus    in,    without   histo- 

logic change,  case  reports,  81 
Placental  tuberculosis,  44,  50 

—  case  histories,  73 

—  frequency,  44 

—  pathology,  31 

—  predisposing  factor,  62 

—  summary,  86 
Placentitis,  See  Placenta 
Precaution  when  operating,  303 
Predisposing  causes,  cervicitis,  151 

—  external  genitalia,   108 

—  to  infection,  103 

Pregnancy  and  genital  tuberculosis,  279 

—  osseous  tuberculosis,  279 

—  peritonitis,  279 

Pregnancy  and  tuberculosis,  243 

—  abortion,  270 

choice  of  operation,  270 

consultation,  270 

convalescence,  272 

technic,  271 

—  care  of  child,  278 

—  cause  for  exacerbations,  245 

—  cesarean  section,  249,  276 
condition  of  child,  251 

—  diagnosis  of  pregnancy,  264 

—  fate  of  child,  251 

—  fertility,  244,  253 


Pregnancy  and  tuberculosis,  frequency, 
244 

—  hysterotomy,  272 

—  influence  of  lactation,  259 

—  influence  of  pregnancy  on  the  course 

of  tuberculosis,  254 

—  influence  of  pregnancy  upon  lesions 

other  than  the  lungs,  278 

—  influence     of     tuberculosis     on     the 

course  of  pregnancy,  253 

—  labor,  275 

—  lactation,  249 

—  laryngeal  involvement,  258 

—  law  regarding  marriage,  261 

—  marriage,  261 

—  mortality,  245 

—  nursing,  278 

—  physiology  of  pregnancy,  245 

—  placenta,  248 

—  premature  labor,  indication  for,  276 

—  prophylactic  measures,  261 

—  puerperium,  248,  278 

—  results  of  abortion,  266 

—  sterilization  of  the  tuberculous,  270 
Pregnancy  and  tuberculosis, 

—  susceptibility  of  the  pregnant,  249 

—  treatment,  263 

after  fifth  month,  274 

hygienic,  263 

indications   for  abortion,  265 

pregnancy    prior    to    fifth    month, 

265 

—  tubercle    bacilli    in    maternal    milk, 

259 

—  tuberculin  in,  260 

—  value  of  statistics,  251 
Premature  labor,  indication  in  the  tu- 
berculous, 276 

Preoperative  treatment,  salpingitis,  216 
Primary  genital  infection,  95 

—  by  coitus,  97,  98,  99 

—  experimental,  99 

Primary  foci   in  secondary  genital  tu- 
berculosis,  105 
Prognosis,   cervicitis,   158 

—  external  genitalia,  115 

—  pelvic  inflammatory  disease,  209 

—  pelvic  peritonitis,  209 

—  salpingitis,  209 

Pruritis,  113,  See  External  Genitalia 
Pseudo-carcinoma,  40 
Pseudoneoplasms,   227 
Pseudotuberculous  peritonitis,  338 


INDEX 


355 


Pseudotumors    in    general    peritonitis, 

336 
Puerperium  in  the  tuberculous,  278 
Pulmonary  tuberculosis  and  anesthesia. 

See  Anesthesia 
Pulmonary  tuberculosis  and  pregnancy. 

See  Pregnancy  and  Tuberculosis 
Pyometra,  230 
Pyosalpinx,  method  of  formation,  38 

—  pathology,  38 

—  rupture,  233 

diagnosis,  234 

into  bladder,  235 

into  bowel,  235 

symptoms,  234 

treatment,  235 

—  torsion,  230 

Routes  of  infection,  summary,  102 
Rupture,    tuberculous    adnexa,     symp- 
toms, 234 

Salpingitis,  192 

—  acute,  197 

—  age,  196 

—  anesthesia,  215 

—  and  adenomyoma,  228 

—  and  results,  211,  220 

—  carcinoma  and,  224 

—  cervicitis  with,  150 

—  chronic  stage,  200 

—  development    of    secondary    lesions 

after  operation,  211,  220 

—  diagnosis,  204 

—  diagnostic  use  of  tuberculin,  206 

—  differential  diagnosis,  207 
Salpingitis,    etiologic    factor    in    tubal 

pregnancy,  239 

—  frequency,  192 

—  general  peritonitis  with,  326,  327 

—  histologically  suggesting  carcinoma, 

40 

—  isthimica  nodosa,  pathology,  36 

—  mistaken  for  nephritis,  236 

—  mortality,  211 

—  operative  mortality,  220 

—  operative  treatment,  218 

—  palliative  treatment,  216 

—  pathology,  34,  36 

—  and  periappendicitis,  240 

—  physical  signs,  acute  stage,  199 

—  predisposition  to,  195 

—  preoperative  treatment,  216 


Salpingitis,  primary,  193 

—  prognosis,  209 

—  pseudoneoplasms,  227 

—  results  of  operative  treatment,  211, 

220 

—  rupture,  233 

—  secondary,  193 

—  spontaneous  cure,  215 

—  torsion,  230 

—  treatment,  214 

Sarcoma,  differentiation  from  cervici- 
tis, 157 

Scanty  menstruation  in  the  tubercu- 
lous, 291 

Sclerosing  mastitis,  315 

Secondary  genital  infection,  101 

Smega  bacillus,  7 

—  differentiation    from   tubercle    bacil- 

lus, 8 

by  staining,  9 

Spinal  anesthesia,  303 

Sterilization  of  the  tuberculous,  270 

Streptococci,  pelvic  inflammatory  dis- 
ease, differential  diagnosis,  207 

Suppurative  general   peritonitis,  331 

Susceptibility,  fetus,  50 

Syphilis  and  tuberculosis,  differential 
diagnosis,  239 

Temperature,  influence  of  menses  on, 
295 

Tubal  pregnancy,  salpingitis,  etiologic 
factor,  239 

Tubercle  bacillus,  diagnostic  demon- 
stration in  leukorrhea,  11 

—  differential  staining,  9 
from  bacillus  leprae,  10 

from    other   acid    proof   bacteria, 

10 
from  smega  bacillus,  8 

—  in  decidua,  historic,  58 

—  in    fetus   without   histologic   change, 

case  reports,  81 

—  in  fluid  of  general  peritonitis,  339 

—  in   the   hypertrophic   variety,   exter- 

nal genitalia,  17 

—  in  leucorrhea,  184 

—  in  maternal  milk,  259 

—  in  placenta,  249 

without    histologic    change,    case 

reports,  81 

—  in  ulcerative  tuberculosis  of  the  ex- 

ternal genitalia,  17 


356 


INDEX 


Tubercle   bacillus,   organisms   likely   to 
be  mistaken  for,  8 

—  variety   causing   general   peritonitis, 

333 
Tuberculin, 

—  diagnosis  in  salpingitis,  206 
diagnostic  use,  11 

practical      value      in      diagnosis, 

12 
in     pregnancy    and     tuberculosis, 

260 
Tuberculosis  and  carcinoma,  225 

—  cancer  and,  318 

—  genital  as  primary  focus  for  spread, 

237 
— ■  in  hernia,  237 

—  neoplasms  and,  318 

—  non-malignant   tumors   of   the   geni- 

tal tract  and,  226 

—  pregnancy  and,  243 

—  syphilis  and,  239 

—  wound  infection,  239 

Tumors,  benign  and  tuberculous,  226 

—  differentiation  from  cervicitis,  157 

—  and  tuberculosis,  224,  318 

Ulcerative  cervicitis,  155 

—  pathology,  20 
Ulcerative  endometritis,  183 

—  pathology,  24 

Ulcerative     external      genitalia,      109, 

113 
Ulcerative  tuberculosis  of  the  external 

genitalia,  pathology,  16 


Ulcerative  vaginitis,  142 

— 'pathology,  18 

Umbilical  fistula  in  general  peritonitis, 

344 
Urethra,  See  External  Genitalia 
Urethritis,  See  External  Genitalia 

Vagina,  See  Vaginitis 
Vaginitis,  140 

—  biopsy,  6 

—  case  histories,  144 

—  diagnosis,  143 

—  etiology,   140 

—  frequency,  140 

—  historic,  140 

—  hypertrophic  variety,  142 
hypertrophic  pathology,  19 

—  miliary  variety,  142 
pathology,  19 

— ■  pseudoneoplasms,  227 

—  symptoms,  141 

—  treatment,  144 

—  ulcerative,  142 
pathology,  18 

—  varieties,  142 
pathology,  18 

Vicarious   menstruation   in   pulmonary 

tuberculosis,  284,  294 
Vulva,  See  External  Genitalia 
Vulvitis,  See  External  Genitalia 
Vulvovaginal      Gland,      See   External 

Genitalia 

Wound  infection,  239 


(1) 


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